Aerosol pirfenidone and pyridone analog compounds and uses thereof

ABSTRACT

Disclosed herein are formulations of pirfenidone or pyridone analog compounds for aerosolization and use of such formulations for aerosol administration of pirfenidone or pyridone analog compounds for the prevention or treatment of various fibrotic and inflammatory diseases, including disease associated with the lung, heart, kidney, liver, eye and central nervous system. In some embodiments, pirfenidone or pyridone analog compound formulations and delivery options described herein allow for efficacious local delivery of pirfenidone or pyridone analog compound. Compositions include all formulations, kits, and device combinations described herein. Methods include inhalation procedures, indications and manufacturing processes for production and use of the compositions described.

PRIORITY CLAIM

This application is a continuation of U.S. patent application Ser. No.15/495,806, filed Apr. 24, 2017, which is a divisional of U.S. patentapplication Ser. No. 14/593,935, filed Jan. 9, 2015, which claims thebenefit of priority from U.S. Provisional Application No. 61/925,791,filed on Jan. 10, 2014; U.S. Provisional Application No. 61/951,686,filed on Mar. 12, 2014; U.S. Provisional Application No. 61/977,529,filed on Apr. 9, 2014; U.S. Provisional Application No. 62/000,473,filed on May 19, 2014, and herein incorporated by reference in theirentirety.

FIELD OF THE INVENTION

The present invention relates in its several embodiments to liquid, drypowder and metered-dose formulations for therapeutic inhaled delivery ofpyridone compositions such as pirfenidone to desired anatomical sites,for treatment and/or prophylaxis of a variety of pulmonary, neurologic,cardiovascular and solid organ disease conditions.

BACKGROUND OF THE INVENTION

A number of undesirable pulmonary diseases such as interstitial lungdisease (ILD; and sub-class diseases therein), chronic obstructivepulmonary disease (COPD; and sub-class diseases therein), asthma, andfibrotic indications of the kidney, heart and eye, the diseases areinitiated from an external challenge. By non-limiting example, theseeffectors can include infection, cigarette smoking, environmentalexposure, radiation exposure, surgical procedures and transplantrejection. However, other causes related to genetic disposition and theeffects of aging may also be attributed. Described herein arecompositions of pirfenidone or a pyridone analog compound that aresuitable for inhalation delivery to the lungs and/or systemiccompartment and methods of using such compositions.

SUMMARY

According to a certain embodiment of the present invention, there isprovided a pirfenidone or pyridone analog compound formulationcomposition for oral pulmonary or intranasal inhalation delivery,comprising formulations for aerosol administration of pirfenidone orpyridone analog compounds for the prevention or treatment of variousfibrotic and inflammatory diseases, including disease associated withthe lung, heart, kidney, liver, eye and central nervous system.

In one aspect, described herein is a method for the treatment of lungdisease in a mammal comprising administering a dose of pirfenidone or apyridone analog compound by inhalation to the mammal in need thereof ona continuous dosing schedule. In some embodiments, the continuous dosingschedule includes administering a dose of pirfenidone or a pyridoneanalog compound daily, every other day, every third day, every fourthday, every fifth day, every sixth day, weekly, biweekly, monthly orbimonthly. In some embodiments, the dosing schedule, whether daily orless than daily, includes administering one, two, three, or more thanthree doses of pirfenidone or a pyridone analog compound on the days ofdosing. In some embodiments, each inhaled dose of pirfenidone or apyridone analog compound is administered with a nebulizer, a metereddose inhaler, or a dry powder inhaler. In some embodiments, each inhaleddose comprises an aqueous solution of pirfenidone or a pyridone analogcompound. In some embodiments, each inhaled dose comprises from about0.1 mL to about 6 mL of an aqueous solution of pirfenidone or a pyridoneanalog compound, wherein the concentration of pirfenidone or pyridoneanalog compound in the aqueous solution is from about 0.1 mg/mL andabout 60 mg/mL and the osmolality of the of the aqueous solution is fromabout 50 mOsmol/kg to about 6000 mOsmol/kg. In some embodiments, theaqueous solution of each inhaled dose further comprises one or moreadditional ingredients selected from co-solvents, tonicity agents,sweeteners, surfactants, wetting agents, chelating agents,anti-oxidants, salts, and buffers. In some embodiments, the aqueoussolution of each inhaled dose further comprises a citrate buffer orphosphate buffer, and one or more salts selected from the groupconsisting of sodium chloride, magnesium chloride, sodium bromide,magnesium bromide, calcium chloride and calcium bromide. In someembodiments, the aqueous solution of each inhaled dose comprises: water;pirfenidone or pyridone analog compound at a concentration from about0.1 mg/mL to about 20 mg/mL; one or more salts, wherein the total amountof the one or more salts is from about 0.01% to about 2.0% by weight ofthe weight of aqueous solution; and optionally a phosphate buffer thatmaintains the pH of the solution from about pH 5.0 to about pH 8.0, orcitrate buffer than maintains the pH of the solution from about 4.0 toabout 7.0; and the osmolality of the of the aqueous solution is fromabout 50 mOsmol/kg to about 2000 mOsmol/kg. In some embodiments, eachinhaled dose is administered with a liquid nebulizer. In someembodiments, the liquid nebulizer: (i) after administration of theinhaled dose, achieves lung deposition of at least 7% of the pirfenidoneor pyridone analog compound administered to the mammal; (ii) provides aGeometric Standard Deviation (GSD) of emitted droplet size distributionof the aqueous solution of about 1.0 μm to about 2.5 μm; (iii) provides:a) a mass median aerodynamic diameter (MMAD) of droplet size of theaqueous solution emitted with the high efficiency liquid nebulizer ofabout 1 μm to about 5 μm; b) a volumetric mean diameter (VMD) of about 1μm to about 5 μm; and/or c) a mass median diameter (MMD) of about 1 μmto about 5 μm; (iv) provides a fine particle fraction (FPF=% ≤5 tam) ofdroplets emitted from the liquid nebulizer of at least about 30%; (v)provides an output rate of at least 0.1 mL/min; and/or (vi) provides atleast about 25% of the aqueous solution to the mammal. In someembodiments, a) the lung tissue Cmax of pirfenidone or pyridone analogcompound from each inhaled dose is at least equivalent to or greaterthan a lung tissue Cmax of up to 801 mg of an orally administered dosageof pirfenidone or pyridone analog compound; and/or b) the blood AUC₀₋₂₄of pirfenidone or pyridone analog compound from each inhaled dose thatis directly administered to the lungs of the mammal is less than orequivalent to the blood AUC₀₋₂₄ of up to 801 mg of an orallyadministered dosage of pirfenidone or pyridone analog compound. In someembodiments, the blood AUC₀₋₂₄ of pirfenidone or pyridone analogcompound from each inhaled dose is less than the blood AUC₀₋₂₄ of up to801 mg of an orally administered dosage of pirfenidone or pyridoneanalog compound. In some embodiments, the blood AUC₀₋₂₄ of pirfenidoneor pyridone analog compound from each inhaled dose is less than 80%,less than 70%, less than 60%, less than 50%, less than 40%, less than30%, less than 20%, less than 10%, less than 5%, less than 2.5%, lessthan 1.0%, less than 0.5%, less than 0.25%, less than 0.1%, less than0.05%, less than 0.025% or less than 0.01% of the blood AUC₀₋₂₄ of up to801 mg of an orally administered dosage of pirfenidone or pyridoneanalog compound. In some embodiments, the blood AUC₀₋₂₄ of pirfenidoneor pyridone analog compound from each inhaled dose is between 0.01-90%,0.01-80%, 0.01-70%, 0.01-60%, 0.01-50%, 0.01-40%, 0.01-30%, 0.01-20%,0.01-10%, 0.01-5%, 0.01-2.5%, 0.01-1%, 0.01-0.1%, 5-90%, between 5-80%,between 5-70%, between 5-60%, between 5-50%, between 5-40%, between5-30%, between 5-20%, between 5-10%, between 1-5%, between 1-10%,between 1-20%, between 1-30%, between 1-40%, between 1-50%, between1-60%, between 1-70%, between 1-80%, or between 1-90% of the bloodAUC₀₋₂₄ of up to 801 mg of an orally administered dosage of pirfenidoneor pyridone analog compound. In some embodiments, wherein each inhaleddose is less than ½ of the up to 801 mg of an orally administered dosageof pirfenidone or pyridone analog compound. In some embodiments, whereineach inhaled dose is less than ½, ⅓, ¼, ⅕, ⅙, ⅛, 1/10, 1/20, 1/40, 1/50,1/75, 1/100, 1/200, 1/300, or 1/400 of the up to 801 mg of an orallyadministered dosage of pirfenidone or pyridone analog compound. In someembodiments, the pirfenidone or a pyridone analog compound isadministered at least once a week. In some embodiments, the pirfenidoneor a pyridone analog compound is administered on a continuous dailydosing schedule. In some embodiments, the pirfenidone or a pyridoneanalog compound is administered once a day, twice a day, or three timesa day. In some embodiments, the lung disease is idiopathic pulmonaryfibrosis, lung cancer or pulmonary hypertension. In some embodiments,the lung disease is idiopathic pulmonary fibrosis. In some embodiments,the lung disease is pulmonary hypertension. In some embodiments, thelung disease is pulmonary hypertension secondary to interstitial lungdisease. In some embodiments, the lung disease is cancer. In someembodiments, the lung disease is lung cancer. In some embodiments, thelung disease is lung cancer where in the therapeutic target is tumorstroma. In some embodiments, the lung disease is lung cancer and thetreatment comprises inhibiting, reducing or slowing the growth of lungtumor stroma. In some embodiments, the method further comprisesadministration of one or more additional therapeutic agents to themammal.

In another aspect, described herein is a method for the treatment oflung disease in a mammal comprising: administering a dose of pirfenidoneor a pyridone analog compound by inhalation to the mammal in needthereof, wherein the blood AUC₀₋₂₄ of pirfenidone or pyridone analogcompound from the inhaled dose is less than the blood AUC₀₋₂₄ of up to801 mg of an orally administered dosage of pirfenidone or pyridoneanalog compound. In some embodiments, the blood AUC₀₋₂₄ of pirfenidoneor pyridone analog compound from each inhaled dose is less than 80%,less than 70%, less than 60%, less than 50%, less than 40%, less than30%, less than 20%, less than 10%, less than 5%, less than 2.5%, lessthan 1.0%, less than 0.5%, less than 0.25%, less than 0.1%, less than0.05%, less than 0.025% or less than 0.01% of the blood AUC₀₋₂₄ of up to801 mg of an orally administered dosage of pirfenidone or pyridoneanalog compound. In some embodiments, the blood AUC₀₋₂₄ of pirfenidoneor pyridone analog compound from each inhaled dose is between 0.01-90%,0.01-80%, 0.01-70%, 0.01-60%, 0.01-50%, 0.01-40%, 0.01-30%, 0.01-20%,0.01-10%, 0.01-5%, 0.01-2.5%, 0.01-1%, 0.01-0.1%, 5-90%, between 5-80%,between 5-70%, between 5-60%, between 5-50%, between 5-40%, between5-30%, between 5-20%, between 5-10%, between 1-5%, between 1-10%,between 1-20%, between 1-30%, between 1-40%, between 1-50%, between1-60%, between 1-70%, between 1-80%, or between 1-90% of the bloodAUC₀₋₂₄ of up to 801 mg of an orally administered dosage of pirfenidoneor pyridone analog compound. In some embodiments, the inhaled dose ofpirfenidone or pyridone analog compound is administered with anebulizer, a metered dose inhaler, or a dry powder inhaler. In someembodiments, the inhaled dose comprises an aqueous solution ofpirfenidone or a pyridone analog compound and the dose is administeredwith a liquid nebulizer. In some embodiments, each inhaled dose that isdirectly administered to the lungs of the mammal comprises from about0.1 mL to about 6 mL of an aqueous solution of pirfenidone or a pyridoneanalog compound, wherein the concentration of pirfenidone or pyridoneanalog compound in the aqueous solution is from about 0.1 mg/mL andabout 60 mg/mL and the osmolality of the of the aqueous solution is fromabout 50 mOsmol/kg to about 6000 mOsmol/kg. In some embodiments, theaqueous solution of each inhaled dose further comprises: one or moreadditional ingredients selected from co-solvents, tonicity agents,sweeteners, surfactants, wetting agents, chelating agents,anti-oxidants, salts, and buffers. In some embodiments, the aqueoussolution of each inhaled dose further comprises: a citrate buffer orphosphate buffer, and one or more salts selected from the groupconsisting of sodium chloride, magnesium chloride, sodium bromide,magnesium bromide, calcium chloride and calcium bromide. In someembodiments, the aqueous solution of each inhaled dose comprises: water;pirfenidone or pyridone analog compound at a concentration from about0.1 mg/mL to about 20 mg/mL; one or more salts, wherein the total amountof the one or more salts is from about 0.01% to about 2.0% by weight ofthe weight of aqueous solution; and optionally a phosphate buffer thatmaintains the pH of the solution from about pH 5.0 to about pH 8.0, orcitrate buffer than maintains the pH of the solution from about 4.0 toabout 7.0. In some embodiments, the inhaled dose of pirfenidone or apyridone analog compound is administered on a continuous dosingschedule. In some embodiments, the lung disease is idiopathic pulmonaryfibrosis, lung cancer or pulmonary hypertension. In some embodiments,the lung disease is idiopathic pulmonary fibrosis. In some embodiments,the lung disease is pulmonary hypertension. In some embodiments, thelung disease is pulmonary hypertension secondary to interstitial lungdisease. In some embodiments, the lung disease is cancer. In someembodiments, the lung disease is lung cancer. In some embodiments, thelung disease is lung cancer where in the therapeutic target is tumorstroma. In some embodiments, the lung disease is lung cancer and thetreatment comprises inhibiting, reducing or slowing the growth of lungtumor stroma. In some embodiments, the method further comprisesadministration of one or more additional therapeutic agents to themammal.

In one aspect, described herein is an aqueous solution for nebulizedinhalation administration comprising: water; pirfenidone, or a pyridoneanalog compound, at a concentration from about 0.1 mg/mL to about 20mg/mL; sodium citrate; citric acid; sodium chloride; and sodiumsaccharin. In some embodiments, the aqueous solution comprises: water;pirfenidone, or a pyridone analog compound, at a concentration fromabout 1 mg/mL to about 20 mg/mL; sodium citrate; citric acid; sodiumchloride; and sodium saccharin. In some embodiments, the aqueoussolution comprises about 3.5 mM sodium citrate and about 1.5 mM citricacid. In some embodiments, the osmolality of the aqueous solution isfrom about 50 mOsmol/kg to about 1000 mOsmol/kg. In some embodiments,the osmolality of the aqueous solution is from about 50 mOsmol/kg toabout 800 mOsmol/kg. In some embodiments, the osmolality of the aqueoussolution is from about 50 mOsmol/kg to about 700 mOsmol/kg. In someembodiments, the osmolality of the aqueous solution is from about 100mOsmol/kg to about 600 mOsmol/kg. In some embodiments, the aqueoussolution comprises about 150 mM of sodium chloride. In some embodiments,the aqueous solution comprises about 0.1 mM to about 1 mM of sodiumsaccharin.

In one aspect, described herein is an aqueous solution for nebulizedinhalation administration comprising: water; pirfenidone at aconcentration from about 0.1 mg/mL to about 20 mg/mL; sodium citrate;citric acid; sodium chloride; and sodium saccharin; wherein the pH isabout 4.0 to about 7.0. In some embodiments, the aqueous solutioncomprises: water; pirfenidone at a concentration from about 1 mg/mL toabout 20 mg/mL; sodium citrate; citric acid; about 100-200 mM of sodiumchloride; and sodium saccharin. In some embodiments, the sodium citrateconcentration and the citric acid concentration is in a range of 1-10 mMand the aqueous solution has a pH of about 5-6, wherein the pH isoptionally achieved by addition of acid or base. In some embodiments,the acid is hydrochloric acid. In some embodiments, the base is sodiumhydroxide. In some embodiments, the aqueous solution comprises about 3.5mM sodium citrate and about 1.5 mM citric acid. In some embodiments, theosmolality of the aqueous solution is from about 50 mOsmol/kg to about1000 mOsmol/kg. In some embodiments, the aqueous solution comprisesabout 150 mM of sodium chloride. In some embodiments, the aqueoussolution comprises about 0.1 mM to about 1 mM of sodium saccharin. Insome embodiments, the pH of the aqueous solution is about 5.5; and theosmolality of the aqueous solution is from about 100 mOsmol/kg to about500 mOsmol/kg. In some embodiments, the pH of the aqueous solution isabout 5.5; and the osmolality of the aqueous solution is from about 200mOsmol/kg to about 500 mOsmol/kg. In some embodiments, the pH of theaqueous solution is about 5.5; and the osmolality of the aqueoussolution is from about 250 mOsmol/kg to about 500 mOsmol/kg.

In one aspect, described herein is an aqueous solution for nebulizedinhalation administration consisting essentially of: water; pirfenidoneat a concentration from about 0.1 mg/mL to about 20 mg/mL; sodiumcitrate; citric acid; sodium chloride; and sodium saccharin; wherein thepH is about 4.0 to about 7.0. In some embodiments, the aqueous solutionconsists essentially of: water; pirfenidone at a concentration fromabout 1 mg/mL to about 20 mg/mL; sodium citrate; citric acid; about100-200 mM of sodium chloride; and sodium saccharin. In someembodiments, the sodium citrate concentration and the citric acidconcentration is in a range of 1-10 mM and the aqueous solution has a pHof about 5-6, wherein the pH is optionally achieved by addition of acidor base. In some embodiments, the acid is hydrochloric acid. In someembodiments, the base is sodium hydroxide. In some embodiments, theaqueous solution comprises about 3.5 mM sodium citrate and about 1.5 mMcitric acid. In some embodiments, the osmolality of the aqueous solutionis from about 50 mOsmol/kg to about 1000 mOsmol/kg. In some embodiments,the concentration of sodium chloride in the aqueous solution is about150 mM. In some embodiments, the concentration of sodium saccharin inthe aqueous solution is about 0.1 mM to about 1 mM. In some embodiments,the pH of the aqueous solution is about 5.5; and the osmolality of theaqueous solution is from about 100 mOsmol/kg to about 500 mOsmol/kg. Insome embodiments, the pH of the aqueous solution is about 5.5; and theosmolality of the aqueous solution is from about 200 mOsmol/kg to about500 mOsmol/kg. In some embodiments, the pH of the aqueous solution isabout 5.5; and the osmolality of the aqueous solution is from about 250mOsmol/kg to about 500 mOsmol/kg.

In another aspect, described herein is a unit dosage adapted for use ina liquid nebulizer comprising from about 0.5 mL to about 6 mL of theaqueous solution described herein. In some embodiments, the liquidnebulizer is a jet nebulizer, an ultrasonic nebulizer, a pulsatingmembrane nebulizer, a nebulizer comprising a vibrating mesh or platewith multiple apertures, a nebulizer comprising a vibration generatorand an aqueous chamber, or a nebulizer that uses controlled devicefeatures to assist inspiratory flow of the aerosolized aqueous solutionto the lungs of the mammal. In some embodiments, the liquid nebulizer:(i) after administration of the inhaled dose, achieves lung depositionof at least 7% of the pirfenidone administered to the mammal; (ii)provides a Geometric Standard Deviation (GSD) of emitted droplet sizedistribution of the aqueous solution of about 1.0 μm to about 2.5 μm;(iii) provides droplets of the aqueous solution emitted with the highefficiency liquid with: a) a mass median aerodynamic diameter (MMAD) ofabout 1 μm to about 5 μm; b) a volumetric mean diameter (VMD) of about 1μm to about 5 μm; and/or c) a mass median diameter (MMD) of about 1 μmto about 5 μm; (iv) provides a fine particle fraction (FPF=% ≤5 μm) ofdroplets emitted from the liquid nebulizer of at least about 30%; (v)provides an output rate of at least 0.1 mL/min; and/or (vi) provides atleast about 25% of the aqueous solution to the mammal.

In one aspect, described herein is a method of decreasing IL-113 levelsin the lungs of a mammal diagnosed with pulmonary fibrosis comprisingadministering by inhalation the aqueous solution described herein to themammal diagnosed with pulmonary fibrosis, wherein the administration ofthe aqueous solution to the mammal decreases IL-1β levels in thebronchial lavage fluid (BAL) of the mammal by at least 10%, 20%, 30%, or40%. In some embodiments, the IL-1β levels in the bronchial lavage fluid(BAL) of the mammal are decreased by at least 30%. In some embodiments,the pulmonary fibrosis is idiopathic pulmonary fibrosis (IPF) orpulmonary fibrosis associated with systemic sclerosis. In someembodiments, the aqueous solution is administered by inhalation to themammal in need thereof with a liquid nebulizer. In some embodiments, theliquid nebulizer is a jet nebulizer, an ultrasonic nebulizer, apulsating membrane nebulizer, a nebulizer comprising a vibrating mesh orplate with multiple apertures, a nebulizer comprising a vibrationgenerator and an aqueous chamber, or a nebulizer that uses controlleddevice features to assist inspiratory flow of the aerosolized aqueoussolution to the lungs of the mammal. In some embodiments, the liquidnebulizer: (i) after administration of the inhaled dose, achieves lungdeposition of at least 7% of the pirfenidone administered to the mammal;(ii) provides a Geometric Standard Deviation (GSD) of emitted dropletsize distribution of the aqueous solution of about 1.0 μm to about 2.5μm; (iii) provides droplets of the aqueous solution emitted with thehigh efficiency liquid with: a) a mass median aerodynamic diameter(MMAD) of about 1 μm to about 5 μm; b) a volumetric mean diameter (VMD)of about 1 μm to about 5 μm; and/or c) a mass median diameter (MMD) ofabout 1 μm to about 5 μm; (iv) provides a fine particle fraction (FPF=%≤5 μm) of droplets emitted from the liquid nebulizer of at least about30%; (v) provides an output rate of at least 0.1 mL/min; and/or (vi)provides at least about 25% of the aqueous solution to the mammal. Insome embodiments, the dose of the aqueous solution of pirfenidone isadministered at least once a week. In some embodiments, the dose of theaqueous solution of pirfenidone is administered on a continuous dailydosing schedule. In some embodiments, the dose of the aqueous solutionof pirfenidone is administered once a day, twice a day, three times aday, four times a day, five times a day, or six times a day. In someembodiments, each dose of the aqueous solution of pirfenidone isadministered within 20 minutes. In some embodiments, the method furthercomprises administration of one or more additional therapeutic agents tothe mammal.

In another aspect, described herein is a method for the treatment oflung disease in a mammal comprising: administering by inhalation a doseof the aqueous solution described herein to the mammal in need thereofon a continuous dosing schedule. In some embodiments, the lung diseaseis idiopathic pulmonary fibrosis, or pulmonary fibrosis associated withsystemic sclerosis, radiation exposure or transplant, lung cancer orpulmonary hypertension. In some embodiments, the lung disease is lungcancer and the treatment comprises inhibiting, reducing or slowing thegrowth of lung tumor stroma. In some embodiments, the aqueous solutionis administered by inhalation to the mammal in need thereof with aliquid nebulizer. In some embodiments, the liquid nebulizer is a jetnebulizer, an ultrasonic nebulizer, a pulsating membrane nebulizer, anebulizer comprising a vibrating mesh or plate with multiple apertures,a nebulizer comprising a vibration generator and an aqueous chamber, ora nebulizer that uses controlled device features to assist inspiratoryflow of the aerosolized aqueous solution to the lungs of the mammal. Insome embodiments, the liquid nebulizer: (i) after administration of theinhaled dose, achieves lung deposition of at least 7% of the pirfenidoneadministered to the mammal; (ii) provides a Geometric Standard Deviation(GSD) of emitted droplet size distribution of the aqueous solution ofabout 1.0 μm to about 2.5 μm; (iii) provides droplets of the aqueoussolution emitted with the high efficiency liquid with: a) a mass medianaerodynamic diameter (MMAD) of about 1 μm to about 5 μm; b) a volumetricmean diameter (VMD) of about 1 μm to about 5 μm; and/or c) a mass mediandiameter (MMD) of about 1 μm to about 5 μm; (iv) provides a fineparticle fraction (FPF=% ≤5 μm) of droplets emitted from the liquidnebulizer of at least about 30%; (v) provides an output rate of at least0.1 mL/min; and/or (vi) provides at least about 25% of the aqueoussolution to the mammal. In some embodiments, the dose of the aqueoussolution of pirfenidone is administered at least once a week. In someembodiments, the dose of the aqueous solution of pirfenidone isadministered on a continuous daily dosing schedule. In some embodiments,the dose of the aqueous solution of pirfenidone is administered once aday, twice a day, three times a day, four times a day, five times a day,or six times a day. In some embodiments, each dose of the aqueoussolution of pirfenidone is administered within 20 minutes. In someembodiments, the method further comprises administration of one or moreadditional therapeutic agents to the mammal.

In one aspect, described herein is an aqueous solution for nebulizedinhalation administration comprising: water; pirfenidone, or a pyridoneanalog compound, at a concentration from about 0.1 mg/mL to about 20mg/mL; wherein the osmolality of the aqueous solution is from about 50mOsmol/kg to about 2000 mOsmol/kg. In some embodiments, the aqueoussolution does not include any cosolvents and/or surfactants. In someembodiments, the solution further comprises one or more additionalingredients selected from buffers and salts. In some embodiments, thebuffer is a citrate buffer or phosphate buffer; and the salt is sodiumchloride or magnesium chloride, or sodium bromide or magnesium bromide,calcium chloride or calcium bromide. In some embodiments, the aqueoussolution comprises: water; pirfenidone or pyridone analog compound at aconcentration from about 1 mg/mL to about 20 mg/mL; wherein the totalamount of the one or more salts is about 0.01% to about 2.0% v/v; andoptionally a phosphate buffer that maintains the pH of the solution fromabout pH 6.0 to about pH 8.0, or citrate buffer than maintains the pH ofthe solution from about 4.0 to about 7.0. In some embodiments, theaqueous solution comprises: water; pirfenidone or pyridone analogcompound at a concentration from about 5 mg/mL to about 18 mg/mL;wherein the total amount of the one or more salts is about 0.01% toabout 2.0% v/v; and optionally a phosphate buffer that maintains the pHof the solution from about pH 6.0 to about pH 8.0, or citrate bufferthan maintains the pH of the solution from about 4.0 to about 7.0;wherein the osmolality of the aqueous solution is from about 50mOsmol/kg to about 2000 mOsmol/kg.

In the embodiments described herein, the inhaled doses are delivered <5,<4, <3, <2, <1 times a day, or less than daily. In some embodiments, theinhaled doses are delivered by nebulization using standard tidalbreathing of continuous flow aerosol or breath actuated aerosol. In suchembodiments of nebulized delivery, delivery times can be <20, <15, <10,<8, <6, <4, <2 or <1 minute. In some embodiments, the inhaled doses aredelivered by inhalation of a dispersed dry powder aerosol using <10, <8,<6, <5, <4, <3, <2 or 1 breath of either a passive dispersion dry powerinhaler or active dispersion dry powder inhaler. In some embodiments,the inhaled doses are delivered by inhalation of aerosol using <10, <8,<6, <5, <4, <3, <2 or 1 breath of a compressed gas metered dose inhalerwith or without a spacer.

In one aspect, described herein is an aqueous solution for nebulizedinhalation administration comprising: water; pirfenidone, or a pyridoneanalog compound, at a concentration from about 10 mg/mL to about 50mg/mL; and one or more co-solvents. In another aspect, described hereinis an aqueous solution for nebulized inhalation administrationcomprising: water; pirfenidone, or a pyridone analog compound, at aconcentration from about 10 mg/mL to about 50 mg/mL; optionally one ormore buffers to maintain the pH between about pH 4.0 to about pH 8.0;and one or more co-solvents. In some embodiments, the pH of the aqueoussolution if from about pH 4.0 to about pH 8.0. In some embodiments, thepH of the aqueous solution if from about pH 6.0 to about pH 8.0. In someembodiments, described herein is an aqueous solution for nebulizedinhalation administration comprising: water; pirfenidone, or a pyridoneanalog compound, at a concentration from about 0.1 mg/mL to about 60mg/mL; and one or more co-solvents, wherein the osmolality of theaqueous solution is from about 50 mOsmol/kg to about 6000 mOsmol/kg. Insome embodiments, pirfenidone, or a pyridone analog compound, is at aconcentration from about 10 mg/mL to about 60 mg/mL. In someembodiments, pirfenidone, or a pyridone analog compound, is at aconcentration from about 10 mg/mL to about 50 mg/mL. In someembodiments, pirfenidone, or a pyridone analog compound, is at aconcentration from about 15 mg/mL to about 50 mg/mL. In someembodiments, pirfenidone, or a pyridone analog compound, is at aconcentration from about 20 mg/mL to about 50 mg/mL. In someembodiments, pirfenidone, or a pyridone analog compound, is at aconcentration from about 25 mg/mL to about 50 mg/mL. In someembodiments, pirfenidone, or a pyridone analog compound, is at aconcentration from about 30 mg/mL to about 50 mg/mL. In someembodiments, the osmolality of the aqueous solution is from about 50mOsmol/kg to about 6000 mOsmol/kg. In some embodiments, the osmolalityof the aqueous solution is from about 50 mOsmol/kg to about 5000mOsmol/kg. In some embodiments, the osmolality of the aqueous solutionis from about 100 mOsmol/kg to about 5000 mOsmol/kg, from about 300mOsmol/kg to about 5000 mOsmol/kg, from about 400 mOsmol/kg to about5000 mOsmol/kg, from about 600 mOsmol/kg to about 5000 mOsmol/kg, fromabout 1000 mOsmol/kg to about 5000 mOsmol/kg, or from about 2000mOsmol/kg to about 5000 mOsmol/kg. In some embodiments, the totalconcentration of co-solvents is from about 1% to about 40% v/v. In someembodiments, the total concentration of co-solvents is from about 1% toabout 30% v/v. In some embodiments, the total concentration ofco-solvents is from about 1% to about 25% v/v. In some embodiments, theone or more co-solvents are selected from ethanol, propylene glycol, andglycerol. In some embodiments, the one or more co-solvents are selectedfrom ethanol, and propylene glycol. In some embodiments, the aqueoussolution includes both ethanol and propylene glycol. In someembodiments, the solution further comprises one or more additionalingredients selected from surfactants, taste masking agents/sweetenersand salts. In some embodiments, the tastemaking agent/sweetener issaccharin, or salt thereof. In some embodiments, the solution furthercomprises one or more additional ingredients selected from surfactantsand salts. In some embodiments, the surfactant is polysorbate 80 orcetylpyridinium bromide. In some embodiments, the salt is sodiumchloride or magnesium chloride. In some embodiments, the surfactant ispolysorbate 80 or cetylpyridinium bromide, and the salt is sodiumchloride or magnesium chloride. In some embodiments, the aqueoussolution includes one more buffers selected from a citrate buffer and aphosphate buffer. In some embodiments, the aqueous solution includes aphosphate buffer. In some embodiments, the aqueous solution includes acitrate buffer. In some embodiments, described herein is from about 0.5mL to about 6 mL of the aqueous solution described herein.

In some embodiments, the solution further comprises one or moreadditional ingredients selected from surfactants, buffers and salts. Insome embodiments, the surfactant is polysorbate 80 or cetylpyridiniumbromide; the buffer is a citrate buffer or phosphate buffer; and thesalt is sodium chloride or magnesium chloride.

In some embodiments, the aqueous solution comprises: water; pirfenidoneor pyridone analog compound at a concentration from about 10 mg/mL toabout 60 mg/mL; one or more co-solvents, wherein the total amount of theone or more co-solvents is about 1% to about 40% v/v, where the one ormore co-solvents are selected from about 1% to about 25% v/v of ethanol,about 1% to about 25% v/v of propylene glycol, and about 1% to about 25%v/v of glycerol; and optionally a phosphate buffer that maintains the pHof the solution from about pH 6.0 to about pH 8.0.

In some embodiments, the aqueous solution comprises: water; pirfenidoneor pyridone analog compound at a concentration from about 15 mg/mL toabout 50 mg/mL; one or more co-solvents, wherein the total amount of theone or more co-solvents if about 1 to about 30% v/v, where the one ormore co-solvents are selected from about 1% to about 10% v/v of ethanol,and about 1% to about 20% v/v of propylene glycol; and optionally aphosphate buffer that maintains the pH of the solution from about pH 6.0to about pH 8.0; wherein the osmolality of the aqueous solution is fromabout 400 mOsmol/kg to about 6000 mOsmol/kg.

In some embodiments, the aqueous solution for nebulized inhalationadministration described herein comprises: water; pirfenidone orpyridone analog compound at a concentration from about 10 mg/mL to about50 mg/mL; optionally a phosphate buffer that maintains the pH of thesolution from about pH 6.0 to about pH 8.0; one or more co-solventsselected from about 1% to about 25% v/v of ethanol and about 1% to about25% v/v of propylene glycol, where the total amount of co-solvents isfrom 1% to 25% v/v. In some embodiments, the aqueous solution fornebulized inhalation administration described herein comprises: water;pirfenidone or pyridone analog compound at a concentration from about 10mg/mL to about 50 mg/mL; optionally a phosphate buffer that maintainsthe pH of the solution from about pH 6.0 to about pH 8.0; about 8% v/vof ethanol; and about 16% v/v of propylene glycol. In some embodiments,the aqueous solution for nebulized inhalation administration describedherein consists essentially of: water; pirfenidone or pyridone analogcompound at a concentration from about 10 mg/mL to about 50 mg/mL;optionally a phosphate buffer that maintains the pH of the solution fromabout pH 6.0 to about pH 8.0; one or more co-solvents selected fromabout 1% to about 25% v/v of ethanol and about 1% to about 25% v/v ofpropylene glycol, where the total amount of co-solvents is from 1% to25% v/v. In some embodiments, the aqueous solution for nebulizedinhalation administration described herein consists essentially of:water; pirfenidone or pyridone analog compound at a concentration fromabout 10 mg/mL to about 50 mg/mL; optionally a phosphate buffer thatmaintains the pH of the solution from about pH 6.0 to about pH 8.0;about 8% v/v of ethanol; and about 16% v/v of propylene glycol. In someembodiments, described herein is from about 0.5 mL to about 6 mL of theaqueous solution described herein.

In some embodiments, described herein is a unit dosage adapted for usein a liquid nebulizer comprising from about 0.5 mL to about 6 mL of anaqueous solution of pirfenidone or a pyridone analog compound, whereinthe concentration of pirfenidone or pyridone analog compound in theaqueous solution is from about 0.1 mg/mL to about 60 mg/mL. In someembodiments, the aqueous solution further comprises one or moreadditional ingredients selected from co-solvents, tonicity agents,sweeteners, surfactants, wetting agents, chelating agents,anti-oxidants, salts, and buffers; and the osmolality of the aqueoussolution is from about 50 mOsmol/kg to about 6000 mOsmol/kg. In someembodiments, the aqueous solution further comprises: one or moreco-solvents selected from ethanol, propylene glycol, and glycerol; andone or both of a citrate buffer or a phosphate buffer. In someembodiments, the aqueous solution comprises: pirfenidone or pyridoneanalog compound dissolved in water at a concentration from about 15mg/mL to about 50 mg/mL; optionally a phosphate buffer that maintainsthe pH of the solution from about pH 6.0 to about pH 8.0; one or moreco-solvents, wherein the total amount of the one or more co-solvents ifabout 1 to about 30% v/v, where the one or more co-solvents are selectedfrom about 1% to about 10% v/v of ethanol, and about 1% to about 20% v/vof propylene glycol; wherein the osmolality of the aqueous solution isfrom about 400 mOsmol/kg to about 6000 mOsmol/kg. In some embodiments,the aqueous solution is as described herein.

In some embodiments, described herein is a kit comprising: a unit dosageof an aqueous solution of pirfenidone or pyridone analog as describedherein in a container that is adapted for use in a liquid nebulizer.

In some embodiments, provided herein is an aqueous droplet ofpirfenidone or pyridone analog compound, wherein the aqueous droplet hasa diameter less than about 5.0 μm. In some embodiments, the aqueousdroplet was produced from a liquid nebulizer and an aqueous solution ofpirfenidone or pyridone analog compound. In some embodiments, theaqueous solution of pirfenidone or pyridone analog compound is asdescribed herein. In some embodiments, the aqueous solution hasconcentration of pirfenidone or pyridone analog compound from about 0.1mg/mL and about 60 mg/mL and an osmolality from about 50 mOsmol/kg toabout 6000 mOsmol/kg. In some embodiments, the aqueous droplet isproduced by a nebulizing an aqueous solution of pirfenidone or pyridoneanalog compound as described herein with a nebulizer. In someembodiments, the nebulizer is a liquid nebulizer. In some embodiments,the nebulizer is a high efficiency liquid nebulizer.

In some embodiments, provided herein is an aqueous aerosol comprising aplurality of aqueous droplets of pirfenidone or pyridone analogcompound. In some embodiments, described herein is an aqueous aerosolcomprising a plurality of aqueous droplets of pirfenidone or pyridoneanalog compound, wherein the plurality of aqueous droplets have avolumetric mean diameter (VMD), mass median aerodynamic diameter (MMAD),and/or mass median diameter (MMD) of less than about 5.0 μm. In someembodiments, the plurality of aqueous droplets was produced from aliquid nebulizer and an aqueous solution of pirfenidone or pyridoneanalog compound. In some embodiments, the aqueous solution hasconcentration of pirfenidone or pyridone analog compound from about 10mg/mL and about 60 mg/mL and an osmolality from about 50 mOsmol/kg toabout 6000 mOsmol/kg. In some embodiments, at least 30% of the aqueousdroplets in the aerosol have a diameter less than about 5 μm. In someembodiments, the aqueous aerosol is produced by a nebulizing an aqueoussolution of pirfenidone or pyridone analog compound as described hereinwith a nebulizer. In some embodiments, the nebulizer is a liquidnebulizer. In some embodiments, the nebulizer is a high efficiencyliquid nebulizer.

In some embodiments, the nebulizer used in any of the methods describedherein is a liquid nebulizer. In some embodiments, the nebulizer used inany of the methods described herein is a jet nebulizer, an ultrasonicnebulizer, a pulsating membrane nebulizer, a nebulizer comprising avibrating mesh or plate with multiple apertures, or a nebulizercomprising a vibration generator and an aqueous chamber. In someembodiments, the nebulizer used in any of the methods described hereinis a nebulizer comprising a vibrating mesh or plate with multipleapertures. In some embodiments, the liquid nebulizer: (i) achieves lungdeposition of at least 7% of the pirfenidone or pyridone analog compoundadministered to the mammal; (ii) provides a Geometric Standard Deviation(GSD) of emitted droplet size distribution of the aqueous solution ofabout 1.0 μm to about 2.5 μm; (iii) provides: a) a mass medianaerodynamic diameter (MMAD) of droplet size of the aqueous solutionemitted with the high efficiency liquid nebulizer of about 1 μm to about5 μm; b) a volumetric mean diameter (VMD) of about 1 jam to about 5 jam;and/or c) a mass median diameter (MMD) of about 1 jam to about 5 jam;(iv) provides a fine particle fraction (FPF=% ≤5 microns) of dropletsemitted from the liquid nebulizer of at least about 30%; (v) provides anoutput rate of at least 0.1 mL/min; and/or (vi) provides at least about25% of the aqueous solution to the mammal.

In some embodiments, the liquid nebulizer is characterized as having atleast two, at least three, at least four, at least five, or all six of(i), (ii), (iii), (iv), (v), (vi). In some embodiments, the liquidnebulizer: (i) achieves lung deposition of at least 5%, at least 6%, atleast 7%, at least 8%, at least 9%, at least 10%, at least 12%, at least14%, at least 16%, at least 18%, at least 20%, at least 25%, at least30%, at least 35%, at least 40% at least 45%, at least 50%, at least55%, at least 60%, at least 65%, at least 70%, at least 75%, or at least80% of the pirfenidone or pyridone analog compound administered to themammal. In some embodiments, the liquid nebulizer: (ii) provides aGeometric Standard Deviation (GSD) of emitted droplet size distributionof the aqueous solution of about 1.0 μm to about 2.5 μm, about 1.2 μm toabout 2.3 μm, about 1.4 μm to about 2.1 μm, or about 1.5 μm to about 2.0μm. In some embodiments, the liquid nebulizer: (iii) provides a) a massmedian aerodynamic diameter (MMAD) of droplet size of the aqueoussolution emitted with the high efficiency liquid nebulizer of about lessthan 5 m or about 1 m to about 5 μm; b) a volumetric mean diameter (VMD)of about less than 5 μm or about 1 μm to about 5 μm; and/or c) a massmedian diameter (MMD) of about less than 5 μm or about 1 μm to about 5μm. In some embodiments, the liquid nebulizer: (iv) provides a fineparticle fraction (FPF=% ≤5 microns) of droplets emitted from the liquidnebulizer of at least about 30%, at least about 35%, at least about 40%,at least about 45%, at least about 50%, at least about 55%, at leastabout 60%, at least about 65%, at least about 70%, at least about 75%,at least about 80%, at least about 85%, or at least about 90%. In someembodiments, the liquid nebulizer: (v) provides an output rate of atleast 0.1 mL/min, of at least 0.2 mL/min, of at least 0.3 mL/min, of atleast 0.4 mL/min, of at least 0.5 mL/min, of at least 0.6 mL/min, of atleast 0.7 mL/min, of at least 0.8 mL/min, of at least 0.9 mL/min, of atleast 1.0 mL/min, or less than about 1.0 mL/min. In some embodiments,the liquid nebulizer: (vi) provides at least about 25%, at least about30%, at least about 35%, at least about 40%, at least about 45%, atleast about 50%, at least about 55%, at least about 60%, at least about65%, at least about 70%, at least about 75%, at least about 80%, atleast about 85%, or at least about 95%, of the aqueous solution to themammal. In some embodiments, the liquid nebulizer provides an respirabledelivered dose (RDD) of at least 5%, at least 6%, at least 7%, at least8%, at least 10%, at least 12%, at least 16%, at least 20%, at least24%, at least 28%, at least 32%, at least 36%, at least 40%, at least45%, at least 50%, at least 55%, at least 60%, at least 65%, at least70%, at least 75%, at least 80%, at least 85%, or at least 90%.

In some embodiments, described herein is a method for the treatment oflung disease in a mammal comprising: administering to mammal in needthereof an aqueous solution comprising pirfenidone or a pyridone analogcompound with a liquid nebulizer. In some embodiments, described hereinis a method for the treatment of lung disease in a mammal comprising:administering to mammal in need thereof an aqueous solution comprisingpirfenidone or a pyridone analog compound with a liquid nebulizer;wherein the aqueous solution comprises water; pirfenidone, or a pyridoneanalog compound, at a concentration from about 0.1 mg/mL to about 60mg/mL; and one or more co-solvents, wherein the osmolality of theaqueous solution is from about 50 mOsmol/kg to about 6000 mOsmol/kg. Insome embodiments, the aqueous solution comprises water; pirfenidone orpyridone analog compound at a concentration from about 10 mg/mL to about60 mg/mL; one or more co-solvents, wherein the total amount of the oneor more co-solvents is about 1% to about 40% v/v, where the one or moreco-solvents are selected from about 1% to about 25% v/v of ethanol,about 1% to about 25% v/v of propylene glycol, and about 1% to about 25%v/v of glycerol; and optionally a phosphate buffer that maintains the pHof the solution from about pH 6.0 to about pH 8.0. In some embodiments,the aqueous solution comprises water; pirfenidone or pyridone analogcompound at a concentration from about 15 mg/mL to about 50 mg/mL; oneor more co-solvents, wherein the total amount of the one or moreco-solvents if about 1 to about 30% v/v, where the one or moreco-solvents are selected from about 1% to about 10% v/v of ethanol, andabout 1% to about 20% v/v of propylene glycol; and optionally aphosphate buffer that maintains the pH of the solution from about pH 6.0to about pH 8.0; wherein the osmolality of the aqueous solution is fromabout 400 mOsmol/kg to about 6000 mOsmol/kg. In some embodiments, thenebulizer is a jet nebulizer, an ultrasonic nebulizer, a pulsatingmembrane nebulizer, a nebulizer comprising a vibrating mesh or platewith multiple apertures, or a nebulizer comprising a vibration generatorand an aqueous chamber. In some embodiments, the liquid nebulizer: (i)achieves lung deposition of at least 7% of the pirfenidone or pyridoneanalog compound administered to the mammal; (ii) provides a GeometricStandard Deviation (GSD) of emitted droplet size distribution of theaqueous solution of about 1.0 μm to about 2.5 m; (iii) provides: a) amass median aerodynamic diameter (MMAD) of droplet size of the aqueoussolution emitted with the high efficiency liquid nebulizer of about 1 μmto about 5 μm; b) a volumetric mean diameter (VMD) of about 1 μm toabout 5 μm; and/or c) a mass median diameter (MMD) of about 1 μm toabout 5 μm; (iv) provides a fine particle fraction (FPF=% ≤5 microns) ofdroplets emitted from the liquid nebulizer of at least about 30%; (v)provides an output rate of at least 0.1 mL/min; and/or (vi) provides atleast about 25% of the aqueous solution to the mammal. In someembodiments, the mammal is a human. In some embodiments, the lungdisease is lung fibrosis and the mammal is a human. In some embodiments,the lung disease is idiopathic pulmonary fibrosis and the mammal is ahuman. In some embodiments, the lung disease is pulmonary hypertensionand the mammal is a human. In some embodiments, the lung disease is Type1, 2, 3, 4 and 5 Pulmonary Hypertension and the mammal is a human. Insome embodiments, the lung disease is cancer and the mammal is a human.In some embodiments, the lung cancer is small cell lung cancer and themammal is a human. In some embodiments, the lung cancer is non-smallcell lung cancer and the mammal is a human. In some embodiments, thepulmonary cancer is large cell carcinoma and the mammal is a human. Insome embodiments, the pulmonary cancer is mesothelioma and the mammal isa human. In some embodiments, the pulmonary cancer is lung carcinoidtumors or bronchial cardinoids and the mammal is a human. In someembodiments, the pulmonary cancer is secondary lung cancer resultingfrom metastatic disease and the mammal is a human. In some embodiments,the pulmonary cancer is bronchioloalveolar carcinoma and the mammal is ahuman. In some embodiments, the pulmonary cancer is sarcoma and themammal is a human. In some embodiments, the pulmonary cancer is alymphoma and the mammal is a human. In some embodiments, the liquidnebulizer delivers from about 0.1 mg to about 360 mg of pirfenidone orpyridone analog compound to the lungs of the mammal in less than about20 minutes with mass median diameter (MMAD) particles sizes from about 1to about 5 micron.

In some embodiments, the lung tissue Cmax and/or AUC of pirfenidone orpyridone analog compound that is obtained after a single administrationof the aqueous solution to the mammal with a liquid nebulizer is aboutthe same or greater than the lung tissue Cmax and/or AUC of pirfenidoneor pyridone analog compound that is obtained after a single dose oforally administered pirfenidone or pyridone analog compound at a dosethat is from about 80% to about 120% of the dose administered with theliquid nebulizer; and/or the plasma Cmax and/or AUC of pirfenidone orpyridone analog compound that is obtained after a single administrationof the aqueous solution to the mammal with a liquid nebulizer is atleast 10% or greater than the plasma Cmax and/or AUC of pirfenidone orpyridone analog compound that is obtained after a single dose of orallyadministered pirfenidone or pyridone analog compound at a dose that isfrom about 80% to about 120% of the dose administered with the liquidnebulizer. In some embodiments, the lung tissue Cmax of pirfenidone orpyridone analog compound that is obtained after a single administrationof the aqueous solution to the mammal with a liquid nebulizer is greaterthan the lung tissue Cmax of pirfenidone or pyridone analog compoundthat is obtained after a single dose of orally administered pirfenidoneor pyridone analog compound at a dose that is from about 80% to about120% of the dose administered with the liquid nebulizer. In someembodiments, the lung tissue AUC of pirfenidone or pyridone analogcompound that is obtained after a single administration of the aqueoussolution to the mammal with a liquid nebulizer is greater than the lungtissue AUC of pirfenidone or pyridone analog compound that is obtainedafter a single dose of orally administered pirfenidone or pyridoneanalog compound at a dose that is from about 80% to about 120% of thedose administered with the liquid nebulizer. In some embodiments, theplasma Cmax of pirfenidone or pyridone analog compound that is obtainedafter a single administration of the aqueous solution to the mammal witha liquid nebulizer is at least 10% or greater than the plasma Cmax ofpirfenidone or pyridone analog compound that is obtained after a singledose of orally administered pirfenidone or pyridone analog compound at adose that is from about 80% to about 120% of the dose administered withthe liquid nebulizer. In some embodiments, the plasma AUC of pirfenidoneor pyridone analog compound that is obtained after a singleadministration of the aqueous solution to the mammal with a liquidnebulizer is at least 10% or greater than the plasma AUC of pirfenidoneor pyridone analog compound that is obtained after a single dose oforally administered pirfenidone or pyridone analog compound at a dosethat is from about 80% to about 120% of the dose administered with theliquid nebulizer.

In some embodiments, the liquid nebulizer delivers from about 0.1 mg toabout 360 mg of pirfenidone or pyridone analog compound to the lungs ofthe mammal in less than about 20 minutes with mass median diameter(MMAD) particles sizes from about 1 to about 5 micron.

In some embodiments, administration with the liquid nebulizer does notinclude an initial dose-escalation period.

In some embodiments, described herein is a method of reducing the riskof gastrointestinal (GI) adverse events in the treatment of a human withpirfenidone or pyridone analog compound, comprising: administering tothe human in need thereof a nebulized aqueous solution comprisingpirfenidone or a pyridone analog compound with a liquid nebulizer;wherein the aqueous solution comprises water; pirfenidone, or a pyridoneanalog compound, at a concentration from about 0.1 mg/mL to about 60mg/mL; and one or more co-solvents, wherein the osmolality of theaqueous solution is from about 50 mOsmol/kg to about 6000 mOsmol/kg. Insome embodiments, the aqueous solution comprises water; pirfenidone orpyridone analog compound at a concentration from about 10 mg/mL to about60 mg/mL; one or more co-solvents, wherein the total amount of the oneor more co-solvents is about 1% to about 40% v/v, where the one or moreco-solvents are selected from about 1% to about 25% v/v of ethanol,about 1% to about 25% v/v of propylene glycol, and about 1% to about 25%v/v of glycerol; and optionally a phosphate buffer that maintains the pHof the solution from about pH 6.0 to about pH 8.0.

In some embodiments, the aqueous solution comprises water; pirfenidoneor pyridone analog compound at a concentration from about 15 mg/mL toabout 50 mg/mL; one or more co-solvents, wherein the total amount of theone or more co-solvents if about 1 to about 30% v/v, where the one ormore co-solvents are selected from about 1% to about 10% v/v of ethanol,and about 1% to about 20% v/v of propylene glycol; and optionally aphosphate buffer that maintains the pH of the solution from about pH 6.0to about pH 8.0; wherein the osmolality of the aqueous solution is fromabout 400 mOsmol/kg to about 6000 mOsmol/kg. In some embodiments, thepirfenidone or pyridone analog is administered to treat lung disease inthe human. In some embodiments, lung disease is idiopathic pulmonaryfibrosis.

In some embodiments, the liquid nebulizer delivers about 0.1 mg to about360 mg of prifenidone or pyridone analog compound to the lungs in lessthan about 20 minutes with mass median diameter (MMAD) particles sizesfrom about 1 to about 5 micron.

In some embodiments, administration with the liquid nebulizer does notinclude an initial dose-escalation period.

In some embodiments, about 0.5 mL to about 6 mL of the aqueous solutionis administered to the mammal with a liquid nebulizer, the solutionhaving a concentration of pirfenidone or pyridone analog compound fromabout 0.1 mg/mL to about 60 mg/mL and the osmolality of the aqueoussolution is from about 50 mOsmol/kg to about 5000 mOsmol/kg; and theliquid nebulizer is a nebulizer comprising a vibrating mesh or platewith multiple apertures.

In some embodiments, the liquid nebulizer delivers about 0.1 mg to about360 mg of prifenidone or pyridone analog compound to the lungs in lessthan about 20 minutes with mass median diameter (MMAD) particles sizesfrom about 1 to about 5 micron. In some embodiments, the aqueoussolution has a pH from about 4.0 to about 8.0 and an osmolality fromabout 400 mOsmol/kg to about 5000 mOsmol/kg.

In some embodiments, described herein is an inhalation system foradministration of pirfenidone or pyridone analog compound to therespiratory tract of a human, the system comprising: (a) about 0.5 mL toabout 6 mL of an aqueous solution of pirfenidone or pyridone analogcompound; and (b) a high efficiency liquid nebulizer. In someembodiments, the aqueous solution is any of the aqueous solutionsdescribed herein. In some embodiments, the concentration of pirfenidoneor pyridone analog compound in the aqueous solution is from about 0.1mg/mL and about 60 mg/mL and the osmolality of the aqueous solution isfrom about 400 mOsmol/kg to about 6000 mOsmol/kg. In some embodiments,the aqueous solution comprises: water; pirfenidone, or a pyridone analogcompound, at a concentration from about 10 mg/mL to about 50 mg/mL;optionally a phosphate buffer that maintains the pH of the solution fromabout pH 6.0 to about pH 8.0; about 1% to about 8% of ethanol; and/orabout 2% to about 16% of propylene glycol. In some embodiments, theaqueous solution is as described herein.

In one aspect, described herein is a method of achieving a lung tissueCmax of pirfenidone or pyridone analog compound that is at least 1.5times, at least 2 times, at least 3 times, at least 4 times, at least 5times, at least 6 times, at least 1.5 times, at least 1.5 times, atleast 1.5 times, at least 1.5 times, at least 7 times, at least 8 times,at least 9 times, at least 10 times, at least 1.5-20 times, at least1.5-15 times, at least 1.5-10 times, at least 1.5-5 times, or at least1.5-3 times a Cmax of up to 801 mg of an orally administered dosage ofpirfenidone or pyridone analog compound, the method comprisingnebulizing an aqueous solution comprising pirfenidone or pyridone analogcompound and administering the nebulized aqueous solution to a human. Insome embodiments, described herein is a method of achieving a lungtissue Cmax of pirfenidone or pyridone analog compound that is at leastequivalent to or greater than a Cmax of up to 801 mg of an orallyadministered dosage of pirfenidone or pyridone analog compound, themethod comprising nebulizing an aqueous solution comprising pirfenidoneor pyridone analog compound and administering the nebulized aqueoussolution to a human.

In one aspect, described herein is a method of achieving a lung tissueAUC₀₋₂₄ of pirfenidone or pyridone analog compound that is at least 1.5times, at least 2 times, at least 3 times, at least 4 times, at least 5times, at least 6 times, at least 1.5 times, at least 1.5 times, atleast 1.5 times, at least 1.5 times, at least 7 times, at least 8 times,at least 9 times, at least 10 times, at least 1.5-20 times, at least1.5-15 times, at least 1.5-10 times, at least 1.5-5 times, or at least1.5-3 times AUC₀₋₂₄ of up to 801 mg of an orally administered dosage ofpirfenidone or pyridone analog compound, the method comprisingnebulizing an aqueous solution comprising pirfenidone or pyridone analogcompound and administering the nebulized aqueous solution to a human. Insome embodiments, described herein is a method of achieving a lungtissue AUC₀₋₂₄ of pirfenidone or pyridone analog compound that is atleast equivalent to or greater than AUC₀₋₂₄ of up to 801 mg of an orallyadministered dosage of pirfenidone or pyridone analog compound, themethod comprising nebulizing an aqueous solution comprising pirfenidoneor pyridone analog compound and administering the nebulized aqueoussolution to a human.

In one aspect, described herein is a method of administering pirfenidoneor a pyridone analog compound to a human, comprising administering anebulized aqueous solution containing the pirfenidone or pyridoneanalog, wherein the lung tissue Cmax achieved with the nebulizedsolution is at least 1.5 times, at least 2 times, at least 3 times, atleast 4 times, at least 5 times, at least 6 times, at least 1.5 times,at least 1.5 times, at least 1.5 times, at least 1.5 times, at least 7times, at least 8 times, at least 9 times, at least 10 times, at least1.5-20 times, at least 1.5-15 times, at least 1.5-10 times, at least1.5-5 times, or at least 1.5-3 times the lung tissue Cmax achieved withan orally administered pirfenidone or pyridone analog compound dosagethat is from 80% to 120% of the dose amount of pirfenidone that isadministered by nebulization.

In one aspect, described herein is a method of administering pirfenidoneor a pyridone analog compound to a human, comprising administering anebulized aqueous solution containing the pirfenidone or pyridoneanalog, wherein the lung tissue Cmax achieved with the nebulizedsolution is at least 1.5 times, at least 2 times, at least 3 times, atleast 4 times, at least 5 times, at least 6 times, at least 1.5 times,at least 1.5 times, at least 1.5 times, at least 1.5 times, at least 7times, at least 8 times, at least 9 times, at least 10 times, at least1.5-20 times, at least 1.5-15 times, at least 1.5-10 times, at least1.5-5 times, or at least 1.5-3 times the lung tissue Cmax achieved withan orally administered pirfenidone or pyridone analog compound dosagethat is from 80% to 120% of the dosage of pirfenidone or pyridone analogcompound in the nebulized aqueous solution of pirfenidone or pyridoneanalog compound. In some embodiments, described herein is a method ofadministering pirfenidone or a pyridone analog compound to a human,comprising administering a nebulized aqueous solution containing thepirfenidone or pyridone analog, wherein the lung tissue Cmax achievedwith the nebulized solution is at least equivalent to or greater thanthe lung tissue Cmax achieved with an orally administered pirfenidone orpyridone analog compound dosage that is from 80% to 120% of the dosageof pirfenidone or pyridone analog compound in the nebulized aqueoussolution of pirfenidone or pyridone analog compound that isadministered.

In some embodiments, described herein is a method of administeringpirfenidone or a pyridone analog compound to a human, comprisingadministering a nebulized aqueous solution containing the pirfenidone orpyridone analog, wherein the plasma AUC₀₋₂₄ achieved with the nebulizedsolution is at least 10% or greater than the plasma AUC₀₋₂₄ achievedwith an orally administered pirfenidone or pyridone analog compounddosage that is from 80% to 120% of the dosage of pirfenidone or pyridoneanalog compound in the nebulized aqueous solution of pirfenidone orpyridone analog compound that is administered.

In one aspect, described herein is a method of administering pirfenidoneor a pyridone analog compound to a human, comprising administering anebulized aqueous solution containing the pirfenidone or pyridoneanalog, wherein the lung tissue AUC₀₋₂₄ achieved with the nebulizedsolution is at least 1.5 times, at least 2 times, at least 3 times, atleast 4 times, at least 5 times, at least 6 times, at least 1.5 times,at least 1.5 times, at least 1.5 times, at least 1.5 times, at least 7times, at least 8 times, at least 9 times, at least 10 times, at least1.5-20 times, at least 1.5-15 times, at least 1.5-10 times, at least1.5-5 times, or at least 1.5-3 times the lung tissue AUC₀₋₂₄ achievedwith an orally administered pirfenidone or pyridone analog compounddosage that is from 80% to 120% of the dosage of pirfenidone or pyridoneanalog compound in the nebulized aqueous solution of pirfenidone orpyridone analog compound. In some embodiments, described herein is amethod of administering pirfenidone or a pyridone analog compound to ahuman, comprising administering a nebulized aqueous solution containingthe pirfenidone or pyridone analog, wherein the lung tissue AUC₀₋₂₄achieved with the nebulized solution is at least 1.5 times the lungtissue AUC₀₋₂₄ achieved with an orally administered pirfenidone orpyridone analog compound dosage that is from 80% to 120% of the dosageof pirfenidone or pyridone analog compound in the nebulized aqueoussolution of pirfenidone or pyridone analog compound.

In one aspect, provided herein is a method of improving thepharmacokinetic profile obtained in a human following a single oral doseadministration of pirfenidone or pyridone analog. In some embodiments,the pirfenidone or pyridone analog is administered to the human to treatlung disease. In some embodiments, the lung disease is lung fibrosis. Insome embodiments, the lung disease is idiopathic pulmonary fibrosis. Insome embodiments, the single oral dose comprises up to about 801 mg ofpirfenidone or pyridone analog compound. In some embodiments, the methodof improving the pharmacokinetic profile comprises the step ofadministering pirfenidone or pyridone analog by inhalation. In someembodiments, the pharmacokinetic profile comprises the lung tissuepharmacokinetic profile. In some embodiments, the pharmacokineticprofile comprises the lung tissue pharmacokinetic profile and/or plasmapharmacokinetic profile. In some embodiments, the pirfenidone orpyridone analog is administered as an aqueous solution with a liquidnebulizer. In some embodiments, the aqueous solution of pirfenidone orpyridone analog is as described herein. In some embodiments, the methodof improving the pharmacokinetic profile further comprises a comparisonof the pharmacokinetic parameters following inhalation administration tothe same parameters obtained following oral administration. In someembodiments, the improvement in pharmacokinetic profile is substantiallythe same as depicted in FIG. 1. In some embodiments, the initialimprovement in pharmacokinetic profile is substantially the same asdepicted in FIG. 1, but the pulmonary half-life is extended providinglonger pulmonary residence time. In some embodiments, a prolongedimprovement in pharmacokinetic profile is obtained by repeated andfrequent administrations of the aqueous solution of pirfenidone orpyridone analog as described herein by inhalation. In some embodiments,repeated administration of pirfenidone or pyridone analog by inhalationprovides more frequent direct lung exposure benefiting the human throughrepeat high Cmax levels. In some embodiments, the inhaled pirfenidone orpyridone analog doses are administered once a day, twice a day, threetimes a day, four time a day, every other day, twice a week, three timesa week, four times a week, five times a week, six times a week, seventimes a week, or any combination thereof. In some embodiments, theimprovement in pharmacokinetic profile is substantially the same asdepicted in FIG. 2. In some embodiments, the initial improvement inpharmacokinetic profile is substantially the same as depicted in FIG. 2,but the pulmonary half-life is extended providing longer pulmonaryresidence time. In some embodiments, a prolonged improvement inpharmacokinetic profile is obtained by repeated and frequentadministrations of the aqueous solution of pirfenidone or pyridoneanalog as described herein by inhalation. In some embodiments, repeatedadministration of pirfenidone or pyridone analog by inhalation providesmore frequent direct lung exposure benefiting the human through repeathigh Cmax levels. In some embodiments, the inhaled pirfenidone orpyridone analog doses are administered once a day, twice a day, threetimes a day, four time a day, every other day, twice a week, three timesa week, four times a week, five times a week, six times a week, seventimes a week, or any combination thereof. In some embodiments, theimprovement in pharmacokinetic profile is substantially the same asdepicted in FIG. 5. In some embodiments, the initial improvement inpharmacokinetic profile is substantially the same as depicted in FIG. 5,but the pulmonary half-life is extended providing longer pulmonaryresidence time. In some embodiments, a prolonged improvement inpharmacokinetic profile is obtained by repeated and frequentadministrations of the aqueous solution of pirfenidone or pyridoneanalog as described herein by inhalation. In some embodiments, repeatedadministration of pirfenidone or pyridone analog by inhalation providesmore frequent direct lung exposure benefiting the human through repeathigh Cmax levels. In some embodiments, the inhaled pirfenidone orpyridone analog doses are administered once a day, twice a day, threetimes a day, four time a day, every other day, twice a week, three timesa week, four times a week, five times a week, six times a week, seventimes a week, or any combination thereof.

In some embodiments, described herein is a pharmaceutical compositionfor pulmonary delivery, comprising a solution of pirfenidone or pyridoneanalog having a concentration greater than about 34 mcg/mL, having anosmolality greater than about 100 mOsmol/kg, and having a pH greaterthan about 4.0. In some embodiments, the pirfenidone or pyridone analogconcentration is greater than about 1.72 mg/mL. In some embodiments, thepirfenidone or pyridone analog concentration is greater than about 86mg/mL. In some embodiments, the pirfenidone or pyridone analog solutionhas a permeant ion concentration from about 30 mM to about 300 mM. Insome embodiments, the permeant ion is chloride or bromide. In someembodiments, the pirfenidone or pyridone analog solution has a pH fromabout 4.0 to about 8.0. In some embodiments, the pirfenidone or pyridoneanalog solution has an osmolality from about 100 mOsmol/kg to about 1000mOsmol/kg. In some embodiments, the pirfenidone or pyridone analogsolution has an osmolality from about 50 mOsmol/kg to about 5000mOsmol/kg. In some embodiments, the composition comprises a tastemasking agent. In some embodiments, the taste masking agent is selectedfrom the group consisting of lactose, sucrose, dextrose, saccharin,aspartame, sucrulose, ascorbate and citrate. In some embodiments, thecomposition comprises a mucolytic agent suitable for pulmonary delivery.In some embodiments, the composition comprises a second anti-fibroticagent suitable for pulmonary delivery. In some embodiments, thecomposition comprises a second anti-inflammatory agent suitable forpulmonary delivery.

In some embodiments, described herein is a pharmaceutical compositionfor pulmonary delivery, comprising a solution of pirfenidone or pyridoneanalog and a taste masking agent, wherein the solution has an osmolalitygreater than about 100 mOsmol/kg, and a pH greater than about 4.0. Insome embodiments, the pirfenidone or pyridone analog concentration isgreater than about 34 mcg/mL. In some embodiments, the pirfenidone orpyridone analog concentration is greater than about 1.72 mg/mL. In someembodiments, the pirfenidone or pyridone analog concentration is greaterthan about 86 mg/mL. In some embodiments, the pirfenidone or pyridoneanalog solution has a permeant ion concentration from about 30 mM toabout 300 mM. In some embodiments, the permeant ion is chloride orbromide. In some embodiments, the pirfenidone or pyridone analogsolution has a pH from about 4.0 to about 8.0. In some embodiments, thepirfenidone or pyridone analog solution has an osmolality from about 100mOsmol/kg to about 1000 mOsmol/kg. In some embodiments, the pirfenidoneor pyridone analog solution has an osmolality from about 50 mOsmol/kg toabout 5000 mOsmol/kg. In some embodiments, the composition comprises ataste masking agent. In some embodiments, the taste masking agent isselected from the group consisting of lactose, sucrose, dextrose,saccharin, aspartame, sucrulose, ascorbate and citrate. In someembodiments, the composition comprises a mucolytic agent suitable forpulmonary delivery. In some embodiments, the composition comprises asecond anti-fibrotic agent suitable for pulmonary delivery. In someembodiments, the composition comprises a second anti-inflammatory agentsuitable for pulmonary delivery.

In some embodiments, described herein is a sterile, single-use containercomprising from about 0.1 mL to about 20 mL of a solution of pirfenidoneor pyridone analog having a concentration greater than about 34 mcg/mL,having an osmolality greater than about 100 mOsmol/kg, and having a pHgreater than about 4.0. In some embodiments, the pirfenidone or pyridoneanalog concentration is greater than about 1.72 mg/mL. In someembodiments, the pirfenidone or pyridone analog concentration is greaterthan about 86 mg/mL. In some embodiments, the pirfenidone or pyridoneanalog solution has a permeant ion concentration from about 30 mM toabout 300 mM. In some embodiments, the permeant ion is chloride orbromide. In some embodiments, the pirfenidone or pyridone analogsolution has a pH from about 4.0 to about 8.0. In some embodiments, thepirfenidone or pyridone analog solution has an osmolality from about 100mOsmol/kg to about 1000 mOsmol/kg. In some embodiments, the pirfenidoneor pyridone analog solution has an osmolality from about 50 mOsmol/kg toabout 5000 mOsmol/kg. In some embodiments, the container furthercomprises a taste masking agent. In some embodiments, the taste maskingagent is selected from the group consisting of lactose, sucrose,dextrose, saccharin, aspartame, sucrulose, ascorbate and citrate. Insome embodiments, the container further comprises a mucolytic agentsuitable for pulmonary delivery. In some embodiments, the containerfurther comprises a second anti-fibrotic agent suitable for pulmonarydelivery. In some embodiments, the container further comprises a secondanti-inflammatory agent suitable for pulmonary delivery.

In one aspect, described herein is a method to treat a pulmonary diseasecomprising inhaling an aerosol of pirfenidone or pyridone analogsolution having a concentration greater than about 34 mcg/mL, having anosmolality greater than about 100 mOsmol/kg, and having a pH greaterthan about 4.0. In some embodiments, the pirfenidone or pyridone analogconcentration is greater than about 1.72 mg/mL. In some embodiments, thepirfenidone or pyridone analog concentration is greater than about 86mg/mL. In some embodiments, the pirfenidone or pyridone analog solutionhas a permeant ion concentration from about 30 mM to about 300 mM. Insome embodiments, the permeant ion is chloride or bromide. In someembodiments, the pirfenidone or pyridone analog solution has a pH fromabout 4.0 to about 8.0. In some embodiments, the pirfenidone or pyridoneanalog solution has an osmolality from about 100 mOsmol/kg to about 1000mOsmol/kg. In some embodiments, the pirfenidone or pyridone analogsolution has an osmolality from about 50 mOsmol/kg to about 5000mOsmol/kg. In some embodiments, the pirfenidone or pyridone analogsolution has a taste masking agent. In some embodiments, the tastemasking agent is selected from the group consisting of lactose, sucrose,dextrose, saccharin, aspartame, sucrulose, ascorbate and citrate. Insome embodiments, the method further comprises administering a mucolyticagent suitable for pulmonary delivery. In some embodiments, the methodfurther comprises administering a second anti-fibrotic agent suitablefor pulmonary delivery. In some embodiments, the method furthercomprises administering a second anti-inflammatory agent suitable forpulmonary delivery. In some embodiments, the pulmonary disease isinterstitial lung disease. In some embodiments, the interstitial lungdisease is idiopathic pulmonary fibrosis. In some embodiments, theinterstitial lung disease is radiation-therapy-induced pulmonaryfibrosis. In some embodiments, the pulmonary disease is chronicobstructive pulmonary disease. In some embodiments, the pulmonarydisease is chronic bronchitis. In some embodiments, the pulmonarydisease is asthma. In some embodiments, the aerosol comprises particleshaving a mean aerodynamic diameter from about 1 micron to about 5microns. In some embodiments, the aerosol has a mean particle size fromabout 1 microns to about 5 microns volumetric mean diameter and aparticle size geometric standard deviation of less than or equal to 3microns. In some embodiments, the inhaling step delivers a dose of aleast 6.8 mcg pirfenidone or pyridone analog. In some embodiments, theinhaling step delivers a dose of a least 340 mcg pirfenidone or pyridoneanalog. In some embodiments, the inhaling step delivers a dose of aleast 740 mcg pirfenidone or pyridone analog. In some embodiments, theinhaling step delivers a dose of a least 1.7 mg pirfenidone or pyridoneanalog. In some embodiments, the inhaling step delivers a dose of aleast 93 mg pirfenidone or pyridone analog. In some embodiments, theinhaling step delivers a dose of a least 463 mg pirfenidone or pyridoneanalog. In some embodiments, the inhaling step is performed in less thanabout 20 minutes. In some embodiments, the inhaling step is performed inless than about 10 minutes. In some embodiments, the inhaling step isperformed in less than about 7.5 minutes. In some embodiments, theinhaling step is performed in less than about 5 minutes. In someembodiments, the inhaling step is performed in less than about 2.5minutes. In some embodiments, the inhaling step is performed in lessthan about 1.5 minutes. In some embodiments, the inhaling step isperformed in less than about 30 seconds. In some embodiments, theinhaling step is performed in less than about 5 breaths. In someembodiments, the inhaling step is performed in less than about 3breaths.

In some embodiments, described herein is a pharmaceutical compositionfor pulmonary delivery, comprising a solution of pirfenidone or pyridoneanalog and a taste masking agent, wherein the solution has an osmolalitygreater than about 50 mOsmol/kg, and a pH greater than about 4.0. Insome embodiments, the pirfenidone or pyridone analog concentration isgreater than about 34 mcg/mL. In some embodiments, the pirfenidone orpyridone analog concentration is greater than about 1.72 mg/mL. In someembodiments, the pirfenidone or pyridone analog concentration is greaterthan about 86 mg/mL. In some embodiments, the pirfenidone or pyridoneanalog solution has a permeant ion concentration from about 30 mM toabout 300 mM. In some embodiments, the permeant ion is chloride orbromide. In some embodiments, the pirfenidone or pyridone analogsolution has a pH from about 4.0 to about 8.0. In some embodiments, thepirfenidone or pyridone analog solution has an osmolality from about 50mOsmol/kg to about 2000 mOsmol/kg. In some embodiments, the compositioncomprises a taste masking agent. In some embodiments, the taste maskingagent is selected from the group consisting of lactose, sucrose,dextrose, saccharin, aspartame, sucrulose, ascorbate and citrate. Insome embodiments, the composition comprises a mucolytic agent suitablefor pulmonary delivery. In some embodiments, the composition comprises asecond anti-fibrotic agent suitable for pulmonary delivery. In someembodiments, the composition comprises a second anti-inflammatory agentsuitable for pulmonary delivery. In some embodiments, the compositioncomprises a second anti-cancer agent suitable for pulmonary delivery. Insome embodiments, the composition comprises a second anti-pulmonaryhypertension agent suitable for pulmonary delivery.

In one aspect, described herein is a method to treat a pulmonary diseasecomprising inhaling an aerosol of pirfenidone or pyridone analogsolution having a concentration greater than about 34 mcg/mL, having anosmolality greater than about 50 mOsmol/kg, and having a pH greater thanabout 4.0. In some embodiments, the pirfenidone or pyridone analogconcentration is greater than about 0.1 mg/mL. In some embodiments, thepirfenidone or pyridone analog concentration is greater than about 86mg/mL. In some embodiments, the pirfenidone or pyridone analog solutionhas a permeant ion concentration from about 30 mM to about 300 mM. Insome embodiments, the permeant ion is chloride or bromide. In someembodiments, the pirfenidone or pyridone analog solution has a pH fromabout 4.0 to about 8.0. In some embodiments, the pirfenidone or pyridoneanalog solution has an osmolality from about 50 mOsmol/kg to about 2000mOsmol/kg. In some embodiments, the pirfenidone or pyridone analogsolution has a taste masking agent. In some embodiments, the tastemasking agent is selected from the group consisting of lactose, sucrose,dextrose, saccharin, aspartame, sucrulose, ascorbate and citrate. Insome embodiments, the method further comprises administering a mucolyticagent suitable for pulmonary delivery. In some embodiments, the methodfurther comprises administering a second anti-fibrotic agent suitablefor pulmonary delivery. In some embodiments, the method furthercomprises administering a second anti-inflammatory agent suitable forpulmonary delivery. In some embodiments, the pulmonary disease isinterstitial lung disease and the mammal is a human. In someembodiments, the interstitial lung disease is idiopathic pulmonaryfibrosis and the mammal is a human. In some embodiments, theinterstitial lung disease is radiation-therapy-induced pulmonaryfibrosis and the mammal is a human. In some embodiments, the pulmonarydisease is chronic obstructive pulmonary disease and the mammal is ahuman. In some embodiments, the pulmonary disease is chronic bronchitisand the mammal is a human. In some embodiments, the pulmonary disease isasthma and the mammal is a human. In some embodiments, the aerosolcomprises particles having a mean aerodynamic diameter from about 1micron to about 5 microns. In some embodiments, the aerosol has a meanparticle size from about 1 microns to about 5 microns volumetric meandiameter and a particle size geometric standard deviation of less thanor equal to 3 microns. In some embodiments, the inhaling step delivers adose of a least 6.8 mcg pirfenidone or pyridone analog. In someembodiments, the inhaling step delivers a dose of a least 340 mcgpirfenidone or pyridone analog. In some embodiments, the inhaling stepdelivers a dose of a least 740 mcg pirfenidone or pyridone analog. Insome embodiments, the inhaling step delivers a dose of a least 1.7 mgpirfenidone or pyridone analog. In some embodiments, the inhaling stepdelivers a dose of a least 93 mg pirfenidone or pyridone analog. In someembodiments, the inhaling step delivers a dose of a least 463 mgpirfenidone or pyridone analog. In some embodiments, the inhaling stepis performed in less than about 20 minutes. In some embodiments, theinhaling step is performed in less than about 10 minutes. In someembodiments, the inhaling step is performed in less than about 7.5minutes. In some embodiments, the inhaling step is performed in lessthan about 5 minutes. In some embodiments, the inhaling step isperformed in less than about 2.5 minutes. In some embodiments, theinhaling step is performed in less than about 1.5 minutes. In someembodiments, the inhaling step is performed in less than about 30seconds. In some embodiments, the inhaling step is performed in lessthan about 5 breaths. In some embodiments, the inhaling step isperformed in less than about 3 breaths.

In one aspect, described herein is a method to treat a pulmonary diseasecomprising inhaling an aerosol of pirfenidone or pyridone analogsolution having a concentration greater than about 34 mcg/mL, having anosmolality greater than about 100 mOsmol/kg, and having a pH greaterthan about 4.0. In some embodiments, the pirfenidone or pyridone analogconcentration is greater than about 0.1 mg/mL. In some embodiments, thepirfenidone or pyridone analog concentration is greater than about 86mg/mL. In some embodiments, the pirfenidone or pyridone analog solutionhas a permeant ion concentration from about 30 mM to about 300 mM. Insome embodiments, the permeant ion is chloride or bromide. In someembodiments, the pirfenidone or pyridone analog solution has a pH fromabout 4.0 to about 8.0. In some embodiments, the pirfenidone or pyridoneanalog solution has an osmolality from about 50 mOsmol/kg to about 2000mOsmol/kg. In some embodiments, the pirfenidone or pyridone analogsolution has a taste masking agent. In some embodiments, the tastemasking agent is selected from the group consisting of lactose, sucrose,dextrose, saccharin, aspartame, sucrulose, ascorbate and citrate. Insome embodiments, the method further comprises administering a mucolyticagent suitable for pulmonary delivery. In some embodiments, the methodfurther comprises administering a second anti-fibrotic or anti-cancer,anti-pulmonary hypertension or anti-infective agent suitable forpulmonary delivery. In some embodiments, the method further comprisesadministering a second anti-inflammatory agent suitable for pulmonarydelivery. In some embodiments, the composition may be co-administeredwith a second anti-fibrotic or anti-cancer, anti-pulmonary hypertensionor anti-infective agent suitable for pulmonary delivery. In someembodiments, the composition co-administered a second anti-inflammatoryagent suitable for pulmonary delivery. In some embodiments, the methodfurther comprises administering a second anti-fibrotic agent suitablefor pulmonary delivery. In some embodiments, the method furthercomprises administering a second anti-inflammatory agent suitable forpulmonary delivery. In some embodiments, the pulmonary disease is lungcancer. In some embodiments, the lung cancer is small cell lung cancer.In some embodiments, the lung cancer is non-small cell lung cancer. Insome embodiments, the pulmonary cancer is large cell carcinoma. In someembodiments, the pulmonary cancer is mesothelioma. In some embodiments,the pulmonary cancer is lung carcinoid tumors or bronchial cardinoids.In some embodiments, the pulmonary cancer is secondary lung cancerresulting from metastatic disease. In some embodiments, the pulmonarycancer is bronchioloalveolar carcinoma. In some embodiments, thepulmonary cancer may be sarcoma. In some embodiments, the pulmonarycancer is may be a lymphoma. In some embodiments, the aerosol comprisesparticles having a mean aerodynamic diameter from about 1 micron toabout 5 microns. In some embodiments, the aerosol has a mean particlesize from about 1 microns to about 5 microns volumetric mean diameterand a particle size geometric standard deviation of less than or equalto 3 microns. In some embodiments, the inhaling step delivers a dose ofa least 6.8 mcg pirfenidone or pyridone analog. In some embodiments, theinhaling step delivers a dose of a least 340 mcg pirfenidone or pyridoneanalog. In some embodiments, the inhaling step delivers a dose of aleast 740 mcg pirfenidone or pyridone analog. In some embodiments, theinhaling step delivers a dose of a least 1.7 mg pirfenidone or pyridoneanalog. In some embodiments, the inhaling step delivers a dose of aleast 93 mg pirfenidone or pyridone analog. In some embodiments, theinhaling step delivers a dose of a least 463 mg pirfenidone or pyridoneanalog. In some embodiments, the inhaling step is performed in less thanabout 20 minutes. In some embodiments, the inhaling step is performed inless than about 10 minutes. In some embodiments, the inhaling step isperformed in less than about 7.5 minutes. In some embodiments, theinhaling step is performed in less than about 5 minutes. In someembodiments, the inhaling step is performed in less than about 2.5minutes. In some embodiments, the inhaling step is performed in lessthan about 1.5 minutes. In some embodiments, the inhaling step isperformed in less than about 30 seconds. In some embodiments, theinhaling step is performed in less than about 5 breaths. In someembodiments, the inhaling step is performed in less than about 3breaths.

In one aspect, described herein is a method to treat a pulmonary diseasecomprising inhaling an aerosol of pirfenidone or pyridone analogsolution having a concentration greater than about 34 mcg/mL, having anosmolality greater than about 100 mOsmol/kg, and having a pH greaterthan about 4.0. In some embodiments, the pirfenidone or pyridone analogconcentration is greater than about 0.1 mg/mL. In some embodiments, thepirfenidone or pyridone analog concentration is greater than about 86mg/mL. In some embodiments, the pirfenidone or pyridone analog solutionhas a permeant ion concentration from about 30 mM to about 300 mM. Insome embodiments, the permeant ion is chloride or bromide. In someembodiments, the pirfenidone or pyridone analog solution has a pH fromabout 4.0 to about 8.0. In some embodiments, the pirfenidone or pyridoneanalog solution has an osmolality from about 50 mOsmol/kg to about 2000mOsmol/kg. In some embodiments, the pirfenidone or pyridone analogsolution has a taste masking agent. In some embodiments, the tastemasking agent is selected from the group consisting of lactose, sucrose,dextrose, saccharin, aspartame, sucrulose, ascorbate and citrate. Insome embodiments, the method further comprises administering a mucolyticagent suitable for pulmonary delivery. In some embodiments, the methodfurther comprises administering a second anti-fibrotic or anti-cancer,anti-pulmonary hypertension or anti-infective agent suitable forpulmonary delivery. In some embodiments, the method further comprisesadministering a second anti-inflammatory agent suitable for pulmonarydelivery. In some embodiments, the composition may be co-administeredwith a second anti-fibrotic or anti-cancer, anti-pulmonary hypertensionor anti-infective agent suitable for pulmonary delivery. In someembodiments, the composition co-administered a second anti-inflammatoryagent suitable for pulmonary delivery. In some embodiments, the methodfurther comprises administering a second anti-fibrotic agent suitablefor pulmonary delivery. In some embodiments, the method furthercomprises administering a second anti-inflammatory agent suitable forpulmonary delivery. In some embodiments, the pulmonary disease ispulmonary hypertension. In some embodiments, the pulmonary hypertensionis Type 1. In some embodiments, the pulmonary hypertension is Type 2. Insome embodiments, the pulmonary hypertension is Type 3. In someembodiments, the pulmonary hypertension is Type 4. In some embodiments,the pulmonary hypertension is Type 5. In some embodiments, the pulmonaryhypertension is secondary to pulmonary fibrosis. In some embodiments,the aerosol comprises particles having a mean aerodynamic diameter fromabout 1 micron to about 5 microns. In some embodiments, the aerosol hasa mean particle size from about 1 microns to about 5 microns volumetricmean diameter and a particle size geometric standard deviation of lessthan or equal to 3 microns. In some embodiments, the inhaling stepdelivers a dose of a least 6.8 mcg pirfenidone or pyridone analog. Insome embodiments, the inhaling step delivers a dose of a least 340 mcgpirfenidone or pyridone analog. In some embodiments, the inhaling stepdelivers a dose of a least 740 mcg pirfenidone or pyridone analog. Insome embodiments, the inhaling step delivers a dose of a least 1.7 mgpirfenidone or pyridone analog. In some embodiments, the inhaling stepdelivers a dose of a least 93 mg pirfenidone or pyridone analog. In someembodiments, the inhaling step delivers a dose of a least 463 mgpirfenidone or pyridone analog. In some embodiments, the inhaling stepis performed in less than about 20 minutes. In some embodiments, theinhaling step is performed in less than about 10 minutes. In someembodiments, the inhaling step is performed in less than about 7.5minutes. In some embodiments, the inhaling step is performed in lessthan about 5 minutes. In some embodiments, the inhaling step isperformed in less than about 2.5 minutes. In some embodiments, theinhaling step is performed in less than about 1.5 minutes. In someembodiments, the inhaling step is performed in less than about 30seconds. In some embodiments, the inhaling step is performed in lessthan about 5 breaths. In some embodiments, the inhaling step isperformed in less than about 3 breaths.

In one aspect, described herein is a method to administer ananti-fibrotic agent to lungs of a patient, comprising: introducing in anebulizer a pirfenidone or pyridone analog solution having aconcentration greater than about 34 mcg/mL, having an osmolality greaterthan about 100 mOsmol/kg, and having a pH greater than about 4.0. Inanother aspect, described herein is a method to administer ananti-inflammatory agent to lungs of a patient, comprising: introducingin a nebulizer a pirfenidone or pyridone analog solution having aconcentration greater than about 34 mcg/mL, having an osmolality greaterthan about 100 mOsmol/kg, and having a pH greater than about 4.0. Insome embodiments, the pirfenidone or pyridone analog concentration isgreater than about 1.72 mg/mL. In some embodiments, the pirfenidone orpyridone analog concentration is greater than about 86 mg/mL. In someembodiments, the pirfenidone or pyridone analog solution has a permeantion concentration from about 30 mM to about 300 mM. In some embodiments,the permeant ion is chloride or bromide. In some embodiments, thepirfenidone or pyridone analog solution has a pH from about 4.0 to about8.0. In some embodiments, the pirfenidone or pyridone analog solutionhas an osmolality from about 100 mOsmol/kg to about 1000 mOsmol/kg. Insome embodiments, the pirfenidone or pyridone analog solution has anosmolality from about 50 mOsmol/kg to about 5000 mOsmol/kg. In someembodiments, the pirfenidone or pyridone analog solution has a tastemasking agent. In some embodiments, the taste masking agent is selectedfrom the group consisting of lactose, sucrose, dextrose, saccharin,aspartame, sucrulose, ascorbate and citrate. In some embodiments, themethod further comprises administering a mucolytic agent suitable forpulmonary delivery. In some embodiments, the mucolytic agent is inhaledseparately from the pirfenidone or pyridone analog solution. In someembodiments, the method further comprises administering a secondanti-fibrotic agent suitable for pulmonary delivery. In someembodiments, the method further comprises administering a secondanti-inflammatory agent suitable for pulmonary delivery.

In one aspect, described herein is a method to treat an extrapulmonarydisease target comprising inhaling an aerosol of pirfenidone or pyridoneanalog solution having a concentration greater than about 34 mcg/mL,having an osmolality greater than about 100 mOsmol/kg, and having a pHgreater than about 4.0 for the purpose of absorbing into the pulmonaryvasculature and exposing downstream disease targets to deliveredpirfenidone or pyridone analog. In some embodiments, the pirfenidone orpyridone analog concentration is greater than about 1.72 mg/mL. In someembodiments, the pirfenidone or pyridone analog concentration is greaterthan about 86 mg/mL. In some embodiments, the pirfenidone or pyridoneanalog solution has a permeant ion concentration from about 30 mM toabout 300 mM. In some embodiments, the permeant ion is chloride orbromide. In some embodiments, the pirfenidone or pyridone analogsolution has a pH from about 4.0 to about 8.0. In some embodiments, thepirfenidone or pyridone analog solution has an osmolality from about 100mOsmol/kg to about 1000 mOsmol/kg. In some embodiments, the pirfenidoneor pyridone analog solution has an osmolality from about 50 mOsmol/kg toabout 5000 mOsmol/kg. In some embodiments, the pirfenidone or pyridoneanalog solution has a taste masking agent. In some embodiments, thetaste masking agent is selected from the group consisting of lactose,sucrose, dextrose, saccharin, aspartame, sucrulose, ascorbate andcitrate. In some embodiments, the method further comprises administeringa mucolytic agent suitable for pulmonary delivery. In some embodiments,the mucolytic agent is inhaled separately from the pirfenidone orpyridone analog solution. In some embodiments, the method furthercomprises administering a second anti-fibrotic agent suitable forpulmonary delivery. In some embodiments, the method further comprisesadministering a second anti-inflammatory agent suitable for pulmonarydelivery. In some embodiments, the extrapulmonary disease target is theheart. In some embodiments, the extrapulmonary disease target is thekidney. In some embodiments, the extrapulmonary disease target is theliver.

In any of the methods described herein using an aerosol or nebulizer todeliver a pirfenidone or pyridone analog compound to the lungs, theaerosol comprises particles having a mean aerodynamic diameter fromabout 1 micron to about 5 microns. In some embodiments, the aerosol hasa mean particle size from about 1 microns to about 5 microns volumetricmean diameter and a particle size geometric standard deviation of lessthan or equal to 3 microns. In some embodiments, the inhaling stepdelivers a dose of a least 6.8 mcg pirfenidone or pyridone analog. Insome embodiments, the inhaling step delivers a dose of a least 340 mcgpirfenidone or pyridone analog. In some embodiments, the inhaling stepdelivers a dose of a least 740 mcg pirfenidone or pyridone analog. Insome embodiments, the inhaling step delivers a dose of a least 17 mgpirfenidone or pyridone analog. In some embodiments, the inhaling stepdelivers a dose of a least 93 mg pirfenidone or pyridone analog. In someembodiments, the inhaling step delivers a dose of a least 463 mgpirfenidone or pyridone analog. In some embodiments, the inhaling stepis performed in less than about 20 minutes. In some embodiments, theinhaling step is performed in less than about 10 minutes. In someembodiments, the inhaling step is performed in less than about 7.5minutes. In some embodiments, the inhaling step is performed in lessthan about 5 minutes. In some embodiments, the inhaling step isperformed in less than about 2.5 minutes. In some embodiments, theinhaling step is performed in less than about 1.5 minutes. In someembodiments, the inhaling step is performed in less than about 30seconds. In some embodiments, the inhaling step is performed in lessthan about 5 breaths. In some embodiments, the inhaling step isperformed in less than about 3 breaths.

In one aspect, described herein is a method to treat a neurologicdisease comprising intranasal inhalation of an aerosol of pirfenidone orpyridone analog solution having a concentration greater than about 34mcg/mL, having an osmolality greater than about 100 mOsmol/kg, andhaving a pH greater than about 4.0. In some embodiments, the pirfenidoneor pyridone analog concentration is greater than about 1.72 mg/mL. Insome embodiments, the pirfenidone or pyridone analog concentration isgreater than about 86 mg/mL. In some embodiments, the pirfenidone orpyridone analog solution has a permeant ion concentration from about 30mM to about 300 mM. In some embodiments, the permeant ion is chloride orbromide. In some embodiments, the pirfenidone or pyridone analogsolution has a pH from about 4.0 to about 8.0. In some embodiments, thepirfenidone or pyridone analog solution has an osmolality from about 100mOsmol/kg to about 1000 mOsmol/kg. In some embodiments, the pirfenidoneor pyridone analog solution has an osmolality from about 50 mOsmol/kg toabout 5000 mOsmol/kg. In some embodiments, the aerosol further comprisesa taste masking agent. In some embodiments, the taste masking agent isselected from the group consisting of lactose, sucrose, dextrose,saccharin, aspartame, sucrulose, ascorbate and citrate. In someembodiments, the method further comprises administering a mucolyticagent suitable for intranasal delivery. In some embodiments, the methodfurther comprises administering a second anti-fibrotic agent suitablefor intranasal delivery. In some embodiments, the method furthercomprises administering a second anti-inflammatory agent suitable forintranasal delivery. In some embodiments, the neurologic disease ismultiple sclerosis. In some embodiments, the aerosol comprises particleshaving a mean aerodynamic diameter from about 1 micron to about 20microns. In some embodiments, the aerosol has a mean particle size fromabout 1 microns to about 20 microns volumetric mean diameter and aparticle size geometric standard deviation of less than or equal to 3microns. In some embodiments, the inhaling step delivers a dose of aleast 6.8 mcg pirfenidone or pyridone analog. In some embodiments, theinhaling step delivers a dose of a least 340 mcg pirfenidone or pyridoneanalog. In some embodiments, the inhaling step delivers a dose of aleast 740 mcg pirfenidone or pyridone analog. In some embodiments, theinhaling step delivers a dose of a least 1.7 mg pirfenidone or pyridoneanalog. In some embodiments, the inhaling step delivers a dose of aleast 93 mg pirfenidone or pyridone analog. In some embodiments, theinhaling step delivers a dose of a least 463 mg pirfenidone or pyridoneanalog. In some embodiments, the inhaling step is performed in less thanabout 20 minutes. In some embodiments, the inhaling step is performed inless than about 10 minutes. In some embodiments, the inhaling step isperformed in less than about 7.5 minutes. In some embodiments, theinhaling step is performed in less than about 5 minutes. In someembodiments, the inhaling step is performed in less than about 2.5minutes. In some embodiments, the inhaling step is performed in lessthan about 1.5 minutes. In some embodiments, the inhaling step isperformed in less than about 30 seconds. In some embodiments, theinhaling step is performed in less than about 5 breaths. In someembodiments, the inhaling step is performed in less than about 3breaths.

In some embodiments, described herein is a method to administer ananti-demylination agent to nasal cavity of a patient, comprising:introducing in a nebulizer a pirfenidone or pyridone analog solutionhaving a concentration greater than about 34 mcg/mL, having anosmolality greater than about 100 mOsmol/kg, and having a pH greaterthan about 4.0. In some embodiments, the pirfenidone or pyridone analogconcentration is greater than about 1.72 mg/mL. In some embodiments, thepirfenidone or pyridone analog concentration is greater than about 86mg/mL. In some embodiments, the pirfenidone or pyridone analog solutionhas a permeant ion concentration from about 30 mM to about 300 mM. Insome embodiments, the permeant ion is chloride or bromide. In someembodiments, the pirfenidone or pyridone analog solution has a pH fromabout 4.0 to about 8.0. In some embodiments, the pirfenidone or pyridoneanalog solution has an osmolality from about 100 mOsmol/kg to about 1000mOsmol/kg. In some embodiments, the pirfenidone or pyridone analogsolution has an osmolality from about 50 mOsmol/kg to about 5000mOsmol/kg. In some embodiments, the solution further comprises a tastemasking agent. In some embodiments, the taste masking agent is selectedfrom the group consisting of lactose, sucrose, dextrose, saccharin,aspartame, sucrulose, ascorbate and citrate. In some embodiments, themethod further comprises administering a mucolytic agent suitable forintranasal delivery. In some embodiments, the mucolytic agent is inhaledseparately from the pirfenidone or pyridone analog solution. In someembodiments, the method further comprises administering a second agentsuitable for intranasal delivery.

In any of the methods described herein involving introducing in anebulizer a pirfenidone or pyridone analog solution, the method involvesa step of opening a sterile single-use container containing betweenabout 0.5 mL to about 10 mL of a solution of pirfenidone or pyridoneanalog solution for introduction into a nebulizer.

In any of the methods described herein involving a nebulizer, theaerosol comprises particles having a mean aerodynamic diameter fromabout 1 micron to about 5 microns. In some embodiments, the aerosol hasa mean particle size from about 1 microns to about 5 microns volumetricmean diameter and a particle size geometric standard deviation of lessthan or equal to 3 microns. In some embodiments, the aerosol comprisesparticles having a mean aerodynamic diameter from about 1 micron toabout 20 microns. In some embodiments, the aerosol has a mean particlesize from about 1 microns to about 20 microns volumetric mean diameterand a particle size geometric standard deviation of less than or equalto 3 microns. In some embodiments, the inhaling step delivers a dose ofa least 6.8 mcg pirfenidone or pyridone analog. In some embodiments, theinhaling step delivers a dose of a least 340 mcg pirfenidone or pyridoneanalog. In some embodiments, the inhaling step delivers a dose of aleast 740 mcg pirfenidone or pyridone analog. In some embodiments, theinhaling step delivers a dose of a least 1.7 mg pirfenidone or pyridoneanalog. In some embodiments, the inhaling step delivers a dose of aleast 93 mg pirfenidone or pyridone analog. In some embodiments, theinhaling step delivers a dose of a least 463 mg pirfenidone or pyridoneanalog. In some embodiments, the inhaling step is performed in less thanabout 20 minutes. In some embodiments, the inhaling step is performed inless than about 10 minutes. In some embodiments, the inhaling step isperformed in less than about 7.5 minutes. In some embodiments, theinhaling step is performed in less than about 5 minutes. In someembodiments, the inhaling step is performed in less than about 2.5minutes. In some embodiments, the inhaling step is performed in lessthan about 1.5 minutes. In some embodiments, the inhaling step isperformed in less than about 30 seconds. In some embodiments, theinhaling step is performed in less than about 5 breaths. In someembodiments, the inhaling step is performed in less than about 3breaths. In some embodiments, the inhaling step is performed in onebreath.

In one aspect, provided herein is a kit comprising: a pharmaceuticalcomposition comprising a pirfenidone or pyridone analog solution in asterile container, wherein the pirfenidone or pyridone analog solutionhas a concentration greater than about 34 mcg/mL, an osmolality greaterthan about 100 mOsmol/kg, and a pH greater than about 4.0, and anebulizer adapted to aerosolize the pirfenidone or pyridone analogsolution for delivery to the middle to lower respiratory tract throughoral inhalation. In some embodiments, the pirfenidone or pyridone analogconcentration is greater than about 1.72 mg/mL. In some embodiments, thepirfenidone or pyridone analog concentration is greater than about 86mg/mL. In some embodiments, the pirfenidone or pyridone analog solutionhas a permeant ion concentration from about 30 mM to about 300 mM. Insome embodiments, the permeant ion is chloride or bromide. In someembodiments, the pirfenidone or pyridone analog solution has a pH fromabout 4.0 to about 8.0. In some embodiments, the pirfenidone or pyridoneanalog solution has an osmolality from about 100 mOsmol/kg to about 1000mOsmol/kg. In some embodiments, the pirfenidone or pyridone analogsolution has an osmolality from about 50 mOsmol/kg to about 5000mOsmol/kg. In some embodiments, the solution further comprises a tastemasking agent. In some embodiments, the taste masking agent is selectedfrom the group consisting of lactose, sucrose, dextrose, saccharin,aspartame, sucrulose, ascorbate and citrate. In some embodiments, thekit further comprises a mucolytic agent suitable for pulmonary delivery.In some embodiments, the kit further comprises a second anti-fibroticagent suitable for pulmonary delivery. In some embodiments, the kitfurther comprises a second anti-inflammatory agent suitable forpulmonary delivery.

In another aspect, provided herein is a kit comprising: a pharmaceuticalcomposition comprising a pirfenidone or pyridone analog solution in asterile container, wherein the pirfenidone or pyridone analog solutionhas a concentration greater than about 34 mcg/mL, an osmolality greaterthan about 100 mOsmol/kg, and a pH greater than about 4.0, and anebulizer adapted to aerosolize the pirfenidone or pyridone analogsolution for delivery to the nasal cavity through intranasal inhalation.

In some embodiments, the pirfenidone or pyridone analog concentration isgreater than about 1.72 mg/mL. In some embodiments, the pirfenidone orpyridone analog concentration is greater than about 86 mg/mL. In someembodiments, the pirfenidone or pyridone analog solution has a permeantion concentration from about 30 mM to about 300 mM. In some embodiments,the permeant ion is chloride or bromide. In some embodiments, thepirfenidone or pyridone analog solution has a pH from about 4.0 to about8.0. In some embodiments, the pirfenidone or pyridone analog solutionhas an osmolality from about 100 mOsmol/kg to about 1000 mOsmol/kg. Insome embodiments, the pirfenidone or pyridone analog solution has anosmolality from about 50 mOsmol/kg to about 5000 mOsmol/kg. In someembodiments, the solution further comprises a taste masking agent. Insome embodiments, the taste masking agent is selected from the groupconsisting of lactose, sucrose, dextrose, saccharin, aspartame,sucrulose, ascorbate and citrate. In some embodiments, the kit furthercomprises a mucolytic agent suitable for intranasal delivery. In someembodiments, the kit further comprises a second anti-fibrotic agentsuitable for intranasal delivery. In some embodiments, the kit furthercomprises a second anti-inflammatory agent suitable for intranasaldelivery.

In one aspect, described herein is a method for treating lung disease,comprising administering pirfenidone or pyridone analog to a middle tolower respiratory tract of a subject having or suspected of havinginterstitial lung disease through oral inhalation of an aerosolcomprising pirfenidone or pyridone analog, wherein the disease isselected from interstitial lung disease, including idiopathic pulmonaryfibrosis and radiation therapy-induced fibrosis; chronic obstructivepulmonary disease; and asthma. In some embodiments, the subject isidentified as having interstitial lung disease. In some embodiments, thesubject is identified as having idiopathic pulmonary fibrosis. In someembodiments, the subject is identified as having radiationtherapy-induced pulmonary fibrosis. In some embodiments, the subject isidentified as having chronic obstructive pulmonary disease. In someembodiments, the subject is identified as having chronic bronchitis. Insome embodiments, the subject is identified as having asthma. In someembodiments, the subject is a subject being mechanically ventilated.

A method for treating extrapulmonary disease, comprising administeringpirfenidone or pyridone analog to a middle to lower respiratory tract ofa subject having or suspected of having extrapulmonary fibrosis,inflammatory and/or toxicity-related diseases through oral inhalation ofan aerosol comprising pirfenidone or pyridone analog for purposes ofpulmonary vascular absorption and delivery to extrapulmonary diseasedtissues, wherein the disease is selected from cardiac fibrosis, kidneyfibrosis, hepatic fibrosis, kidney toxicity and heart toxicity. In someembodiments, the subject is identified as having cardiac fibrosis. Insome embodiments, the subject is identified as having kidney fibrosis.In some embodiments, the subject is identified as having hepaticfibrosis. In some embodiments, the subject is identified as havingkidney toxicity. In some embodiments, the subject is identified ashaving heart toxicity. In some embodiments, the subject is a subjectbeing mechanically ventilated.

In one aspect, described herein is a method for treating neurologicdisease, comprising administering pirfenidone or pyridone analog to thenasal cavity of a subject having or suspected of having neurologicdisease through intranasal inhalation of an aerosol comprisingpirfenidone or pyridone analog for purposes of nasal vascular absorptionand delivery to central nervous system, wherein the disease is multiplesclerosis. In some embodiments, the subject is identified as havingmultiple sclerosis. In some embodiments, the subject is a subject beingmechanically ventilated.

In one aspect, described herein is a pharmaceutical composition forpulmonary delivery, comprising a dry powder containing pirfenidone orpyridone analog having a dosage content greater than about 1%. In someembodiments, the pirfenidone or pyridone analog dose content is greaterthan about 6.8 mcg. In some embodiments, the pirfenidone or pyridoneanalog content is greater than about 340 mcg. In some embodiments, thepirfenidone or pyridone analog content is greater than about 17 mg. Insome embodiments, the pirfenidone or pyridone analog content is greaterthan about 463 mg. In some embodiments, the powder further comprises ablending agent. In some embodiments, the blending agent is selected fromthe group consisting of lactose.

In one aspect, described herein is a pharmaceutical composition forpulmonary delivery, comprising a dry powder containing pirfenidone orpyridone analog having a dosage content greater than about 1%. In yetanother aspect, described herein is a sterile, single-use containercomprising from about 0.5 mg to about 100 mg dry powder containingpirfenidone or pyridone analog having a dosage content greater thanabout 1%. In a further aspect, described is a method to treat apulmonary disease comprising inhalation of a dry powder aerosolcontaining pirfenidone or pyridone dosage content greater than about 1%.In some embodiments, the pirfenidone or pyridone analog dose content isgreater than about 6.8 mcg. In some embodiments, the pirfenidone orpyridone analog content is greater than about 340 mcg. In someembodiments, the pirfenidone or pyridone analog content is greater thanabout 17 mg. In some embodiments, the pirfenidone or pyridone analogcontent is greater than about 463 mg. In some embodiments, the drypowder further comprises a blending agent. In some embodiments, theblending agent is lactose. In some embodiments, the pulmonary disease isinterstitial lung disease. In some embodiments, the interstitial lungdisease is idiopathic pulmonary fibrosis. In some embodiments, theinterstitial lung disease is radiation-therapy-induced pulmonaryfibrosis. In some embodiments, the pulmonary disease is chronicobstructive pulmonary disease. In some embodiments, the pulmonarydisease is chronic bronchitis. In some embodiments, the pulmonarydisease is asthma. In some embodiments, the aerosol comprises particleshaving a mean aerodynamic diameter from about 1 micron to about 5microns. In some embodiments, the aerosol has a mean particle size fromabout 1 microns to about 5 microns volumetric mean diameter and aparticle size geometric standard deviation of less than or equal to 3microns. In some embodiments, the inhaling step delivers a dose of aleast 6.8 mcg pirfenidone or pyidone analog. In some embodiments, theinhaling step delivers a dose of a least 340 mcg pirfenidone or pyidoneanalog. In some embodiments, the inhaling step delivers a dose of aleast 740 mcg pirfenidone or pyidone analog. In some embodiments, theinhaling step delivers a dose of a least 1.7 mg pirfenidone or pyidoneanalog. In some embodiments, the inhaling step delivers a dose of aleast 93 mg pirfenidone or pyidone analog. In some embodiments, theinhaling step delivers a dose of a least 463 mg pirfenidone or pyidoneanalog. In some embodiments, the inhaling step is performed in less thanabout 5 breaths. In some embodiments, the inhaling step is performed inless than about 3 breaths. In some embodiments, the inhaling step isperformed in less than about 2 breaths. In some embodiments, theinhaling step is performed in one breath.

In one aspect, provided herein is a method to administer ananti-fibrotic agent to lungs of a subject, comprising: introducing in adry powder inhaler a pirfenidone or pyridone analog dry powderformulation having a dosage content greater than about 1%. In anotheraspect, provided herein is a method to administer an anti-inflammatoryagent to lungs of a subject, comprising: introducing in a dry powderinhaler a pirfenidone or pyridone analog dry powder formulation having adosage content greater than about 1%. In yet another aspect, providedherein is a method to treat an extrapulmonary disease target comprisinginhalation of a dry powder aerosol containing pirfenidone or pyridonedosage content greater than about 1%. In some embodiments, theextrapulmonary disease target is the heart. In some embodiments, theextrapulmonary disease target is the kidney. In some embodiments, theextrapulmonary disease target is the liver. In yet another aspect,provided herein is a method to treat a neurologic disease comprisingintranasal inhalation of a dry powder aerosol containing pirfenidone orpyridone dosage content greater than about 1%. In some embodiments, theneurologic disease is multiple sclerosis. In yet another aspect,provided herein is a method to administer an anti-demylination agent tonasal cavity of a subject, comprising: introducing in a dry powderinhaler a pirfenidone or pyridone analog dry powder formulation having adosage content greater than about 1%. In some embodiments, thepirfenidone or pyridone analog dose content is greater than about 6.8mcg. In some embodiments, the pirfenidone or pyridone analog content isgreater than about 340 mcg. In some embodiments, the pirfenidone orpyridone analog content is greater than about 17 mg. In someembodiments, the pirfenidone or pyridone analog content is greater thanabout 463 mg. In some embodiments, the dry powder comprises a blendingagent. In some embodiments, the blending agent is lactose. In someembodiments, the aerosol comprises particles having a mean aerodynamicdiameter from about 1 micron to about 5 microns. In some embodiments,the aerosol has a mean particle size from about 1 microns to about 5microns volumetric mean diameter and a particle size geometric standarddeviation of less than or equal to 3 microns. In some embodiments, theaerosol comprises particles having a mean aerodynamic diameter fromabout 1 micron to about 20 microns. In some embodiments, the aerosol hasa mean particle size from about 1 microns to about 20 microns volumetricmean diameter and a particle size geometric standard deviation of lessthan or equal to 3 microns. In some embodiments, the inhaling stepdelivers a dose of a least 6.8 mcg pirfenidone or pyidone analog. Insome embodiments, the inhaling step delivers a dose of a least 340 mcgpirfenidone or pyidone analog. In some embodiments, the inhaling stepdelivers a dose of a least 740 mcg pirfenidone or pyidone analog. Insome embodiments, the inhaling step delivers a dose of a least 1.7 mgpirfenidone or pyidone analog. In some embodiments, the inhaling stepdelivers a dose of a least 17 mg pirfenidone or pyidone analog. In someembodiments, the inhaling step delivers a dose of a least 93 mgpirfenidone or pyidone analog. In some embodiments, the inhaling stepdelivers a dose of a least 463 mg pirfenidone or pyidone analog. In someembodiments, the inhaling step is performed in less than about 5breaths. In some embodiments, the inhaling step is performed in lessthan about 3 breaths. In some embodiments, the inhaling step isperformed in less than about 2 breaths. In some embodiments, theinhaling step is performed in one breath. In some embodiments, themethod further comprises the step of opening a single-use dry powdercontainer holding between about 0.5 mg to about 10 mg dry powderformulation containing pirfenidone or pyridone analog for introductioninto a dry powder inhaler.

In one aspect, described herein is a kit comprising: a pharmaceuticalcomposition comprising a dry powder pirfenidone or pyridone analogformulation in a container, wherein the pirfenidone or pyridone analogdosage content is greater than about 1%; and a dry powder inhaleradapted to aerosolize the pirfenidone or pyridone analog dry powderformulation for delivery to the middle to lower respiratory tractthrough oral inhalation. In another aspect, described herein is a kitcomprising: a pharmaceutical composition comprising a dry powderpirfenidone or pyridone analog formulation in a container, wherein thepirfenidone or pyridone analog dosage content is greater than about 1%,and a dry powder inhaler adapted to aerosolize the pirfenidone orpyridone analog dry powder formulation for delivery to the nasal cavitythrough intranasal inhalation. In some embodiments, the pirfenidone orpyridone analog dose content is greater than about 6.8 mcg. In someembodiments, the pirfenidone or pyridone analog content is greater thanabout 340 mcg. In some embodiments, the pirfenidone or pyridone analogcontent is greater than about 17 mg. In some embodiments, thepirfenidone or pyridone analog content is greater than about 463 mg. Insome embodiments, the powder further comprises a blending agent. In someembodiments, the blending agent is lactose.

In one aspect, described herein is a method for treating lung disease,comprising administering pirfenidone or pyridone analog to a middle tolower respiratory tract of a subject having or suspected of havinginterstitial lung disease through oral inhalation of an aerosolcomprising pirfenidone or pyridone analog, wherein the disease isselected from interstitial lung disease, including idiopathic pulmonaryfibrosis and radiation therapy-induced fibrosis; chronic obstructivepulmonary disease; and asthma. In some embodiments, the subject isidentified as having interstitial lung disease. In some embodiments, thesubject is identified as having idiopathic pulmonary fibrosis. In someembodiments, the subject is identified as having radiationtherapy-induced pulmonary fibrosis. In some embodiments, the subject isidentified as having chronic obstructive pulmonary disease. In someembodiments, the subject is identified as having chronic bronchitis. Insome embodiments, the subject is identified as having asthma. In someembodiments, the subject is a subject being mechanically ventilated.

In one aspect, described herein is a method for treating lung disease,comprising administering pirfenidone or pyridone analog to a middle tolower respiratory tract of a subject having or suspected of havingpulmonary disease through oral inhalation of an aerosol comprisingpirfenidone or pyridone analog, wherein the pulmonary disease is cancer.In some embodiments, the therapeutic target for said pulmonary cancer istumor stroma. In some embodiments, the subject is a subject beingmechanically ventilated.

In one aspect, described herein is a method for treating lung disease,comprising administering pirfenidone or pyridone analog to a middle tolower respiratory tract of a subject having or suspected of havingpulmonary disease through oral inhalation of an aerosol comprisingpirfenidone or pyridone analog, wherein the pulmonary disease ispulmonary hypertension. In some embodiments, the subject is a subjectbeing mechanically ventilated.

In one aspect, described herein is a method for treating extrapulmonarydisease, comprising administering pirfenidone or pyridone analog to amiddle to lower respiratory tract of a subject having or suspected ofhaving extrapulmonary fibrosis, inflammatory and/or toxicity-relateddiseases through oral inhalation of an aerosol comprising pirfenidone orpyridone analog for purposes of pulmonary vascular absorption anddelivery to extrapulmonary diseased tissues, wherein the disease isselected from cardiac fibrosis, kidney fibrosis, hepatic fibrosis,kidney toxicity and heart toxicity.

In some embodiments, the subject is identified as having cardiacfibrosis. In some embodiments, the subject is identified as havingkidney fibrosis. In some embodiments, the subject is identified ashaving hepatic fibrosis. In some embodiments, the subject is identifiedas having kidney toxicity. In some embodiments, the subject isidentified as having heart toxicity. In some embodiments, the subject isa subject being mechanically ventilated.

In one aspect, described herein is a method for treating neurologicdisease, comprising administering pirfenidone or pyridone analog to thenasal cavity of a subject having or suspected of having neurologicdisease through intranasal inhalation of an aerosol comprisingpirfenidone or pyridone analog for purposes of nasal vascular absorptionand delivery to central nervous system, wherein the disease is multiplesclerosis. In some embodiments, the subject is identified as havingmultiple sclerosis. In some embodiments, the subject is a subject beingmechanically ventilated.

In one aspect, described herein is a method of administering pirfenidoneor pyridone analog to treat a patient with idiopathic pulmonary fibrosis(IPF), wherein the patient avoids abnormal liver function exhibited by agrade 2 or higher abnormality following oral administration in one ormore biomarkers of liver function after pirfenidone or pyridone analogadministration, comprising administering to said patient pirfenidone orpyridone analog at doses less than 300 mg per day. In some embodiments,“Grade 2 liver function abnormalities” include elevations in alaninetransaminase (ALT), aspartate transaminase (AST), alkaline phosphatase(ALP), or gamma-glutamyl transferase (GGT) greater than 2.5-times andless than or equal to 5-times the upper limit of normal (ULN). Grade 2liver function abnormalities also include elevations of bilirubin levelsgreater than 1.5-times and less than or equal to 3-times the ULN. Insome embodiments, the pirfenidone or pyridone analog is delivered to thepatient by oral inhalation or intranasal inhalation. In someembodiments, said one or more biomarkers of liver function is selectedfrom the group consisting of alanine transaminase, aspartatetransaminase, bilirubin, and alkaline phosphatase. In some embodiments,the method further comprises the step of measuring one or morebiomarkers of liver function. In some embodiments, the blood Cmaxfollowing administration of pirfenidone or pyridone analog is less than10 mcg/mL. In some embodiments, the blood Cmax following administrationof pirfenidone or pyridone analog is greater than 10 mcg/mL.

In one aspect, described herein is a method of administering pirfenidoneor pyridone analog to treat a patient with idiopathic pulmonary fibrosis(IPF), wherein the patient avoids the incidence of photosensitivityreaction observed following oral administration, comprisingadministering to said patient pirfenidone or pyridone analog at dosesless than 360 mg per day. In some embodiments, the pirfenidone orpyridone analog is delivered to the patient by oral inhalation orintranasal inhalation. In some embodiments, the incidence ofphotosensitivity reaction adverse events is less than about 12%. In someembodiments, the blood Cmax following administration of pirfenidone orpyridone analog is less than 10 mcg/mL. In some embodiments, the bloodCmax following administration of pirfenidone or pyridone analog isgreater than 10 mcg/mL.

In one aspect, described herein is a method of administering pirfenidoneor pyridone analog to treat a patient with idiopathic pulmonary fibrosis(IPF), wherein the patient avoids the incidence of phototoxicityobserved following oral administration, comprising administering to saidpatient pirfenidone or pyridone analog at doses less than 360 mg perday. In some embodiments, the pirfenidone or pyridone analog isdelivered to the patient by oral inhalation or intranasal inhalation. Insome embodiments, the incidence of photosensitivity reaction adverseevents is less than about 12%. In some embodiments, the blood Cmaxfollowing administration of pirfenidone or pyridone analog is less than10 mcg/mL. In some embodiments, the blood Cmax following administrationof pirfenidone or pyridone analog is greater than 10 mcg/mL.

In one aspect, described herein is a method of administering pirfenidoneor pyridone analog to treat a patient with idiopathic pulmonary fibrosis(IPF), wherein the patient avoids the incidence of gastrointestinaladverse events observed following oral administration, by deliveringpirfenidone or pyridone analog directly to the lung by oral inhalationor intranasal inhalation. In some embodiments, gastrointestinal adverseevents observed following oral administration of pirfenidone or pyridoneanalog include, but are not limited to any one or more of the following:dyspepsia, nausea, diarrhea, gastroesophageal reflux disease (GERD) andvomiting. In some embodiments, less than 360 mg per day of pirfenidoneor pyridone analog is delivered to the patient by inhalation. In someembodiments, less than 1000 mg, less than 900 mg, less 600 mg, or lessthan 300 mg per day of pirfenidone or pyridone analog is delivered tothe patient by inhalation. In some embodiments, less than 300 mg per dayof pirfenidone or pyridone analog is delivered per dose to the patientby inhalation. In some embodiments, pirfenidone or pyridone analog isdelivered by inhalation once per day, twice per day, three time a day,or four time a day.

In some embodiments, up to about 360 mg of pirfenidone or pyridoneanalog is delivered to the patient by inhalation per dose. In someembodiments, about 1 mg to about 360 mg, about 10 mg to about 360 mg,about 20 mg to about 360 mg, about 30 mg to about 360 mg, about 40 mg toabout 360 mg, about 50 mg to about 360 mg, about 60 mg to about 70 mg,about 80 mg to about 360 mg, about 90 mg to about 360 mg, about 100 mgto about 360 mg, about 120 mg to about 360 mg, about 140 mg to about 360mg, about 160 mg to about 360 mg, about 180 mg to about 360 mg, or about200 mg to about 360 mg, of pirfenidone or pyridone analog is deliveredto the patient by inhalation per dose. In some embodiments, pirfenidoneor pyridone analog is delivered by inhalation once per day, twice perday, three time a day, or four time a day.

In one aspect, described herein is a pharmaceutical compositioncomprising a therapeutically effective amount of an inhaled agent,wherein the agent is pirfenidone or pyridone analog, wherein the agentis in a particle less than 5 microns in mass mean aerodynamic diameteror less than 10 microns volumetric mean diameter wherein thecomposition, upon inhalation, delivers a dose to the lung greater than 1mcg pirfenidone or pyridone analog compound per gram of adult human lungtissue.

In one aspect, described herein is a pharmaceutical composition foraerosol delivery to the lung, comprising a solution of pirfenidone orpyridone analog containing a divalent cation. In some embodiments, thedivalent cation is selected from the group consisting of calcium, iron,magnesium, and beryllium. In some embodiments, the ratio of pirfenidoneor pyridone analog to divalent cation is within the molar range of 1 toabout 0.1 to 10, in unit increments of about 0.01. By example, 1 toabout 10, 1 to about 9, 1 to about 8, 1 to about 7, 1 to about 6, 1 toabout 5, 1 to about 4, 1 to about 3, 1 to about 2, 1 to about 1.5, 1 toabout 1, 1 to about 0.75, 1 to about 0.5, 1 to about 0.25, and 1 toabout 0.1. In some embodiments, the active pharmaceutical ingredient ispirfenidone or pyridone analog concentration is between 0.1 mg/mL and 50mg/mL in unit increments of about 0.01 mg/mL composition. By example,about 0.1 mg/mL, about 0.5 mg/mL, about 1 mg/mL, about 2 mg/mL, about 3mg/mL, about 4 mg/mL, about 5 mg/mL, about 6 mg/mL, about 7 mg/mL, about8 mg/mL, about 9 mg/mL, about 10 mg/mL, about 15 mg/mL, about 20 mg/mL,about 25 mg/mL, about 30 mg/mL, about 30 mg/mL, about 35 mg/mL, about 40mg/mL, about 45 mg/mL, about 50 mg/mL, about 55 mg/mL, and about 60mg/mL. In some embodiments, the active pharmaceutical ingredient is nota salt of pirfenidone or pyridone analog. In some embodiments, thecomposition is a stable, water-soluble formulation. In some embodiments,the osmolality is greater than about 50 mOsmol/kg composition in unitincrements of about 1 mOsmol/kg. By example, greater than about 50mOsmol/kg, about 100 mOsmol/kg, about 150 mOsmol/kg, about 200mOsmol/kg, about 250 mOsmol/kg, about 300 mOsmol/kg, about 350mOsmol/kg, about 400 mOsmol/kg, about 450 mOsmol/kg, about 500mOsmol/kg, about 550 mOsmol/kg, about 600 mOsmol/kg, about 650mOsmol/kg, about 700 mOsmol/kg, about 750 mOsmol/kg, about 800mOsmol/kg, about 850 mOsmol/kg, about 900 mOsmol/kg, about 950mOsmol/kg, about 1000 mOsmol/kg, greater than about 1500 mOsmol/kg,about 2000 mOsmol/kg, about 2500 mOsmol/kg, greater than about 3000mOsmol/kg, about 3500 mOsmol/kg, about 4000 mOsmol/kg, greater thanabout 4500 mOsmol/kg, about 5000 mOsmol/kg, about 5500 mOsmol/kg, about6000 mOsmol/kg, or greater than about 6000 mOsmol/kg. In someembodiments, the pH is greater than about 3.0 in pH unit increments ofabout 0.1. By example, a pH of about 3, a pH of about 3.5, a pH of about4, a pH of about 4.5, a pH of about 5, a pH of about 5.5, a pH of about6, a pH of about 6.5, a pH of about 7, a pH of about 7.5, a pH of about8, a pH of about 8.5, a pH of about 9, a pH of about 9.5, a pH of about10 a pH of about 10.5, and a pH of about 11. In some embodiments, the pHis balanced by the inclusion of an organic buffer selected from thegroup consisting of citric acid, citrate, malic acid, malate, pyridine,formic acid, formate, piperazine, succinic acid, succinate, histidine,maleate, bis-tris, pyrophosphate, phosphoric acid, phosphate, PIPES,ACES, MES, cacodylic acid, carbonic acid, carbonate, ADA(N-(2-Acetamido)-2-iminodiacetic acid). In some embodiments, thepirfenidone or pyridone analog solution contains a permeant ionconcentration. In some embodiments, the permeant ion is selected fromthe group consisting of bromine, chloride, and lithium. In someembodiments, the permeant ion concentration is from about 30 mM to about300 mM in about 0.1 mM increments. By example, about 30 mM, about 40 mM,about 50 mM, about 60 mM, about 70 mM, about 80 mM, about 90 mM, about100 mm, about 150 mM, about 200 mM, about 250 mM, and about 300 mM. Insome embodiments, the composition further comprises a taste maskingagent. In some embodiments, the taste masking agent is selected from thegroup consisting of lactose, sucrose, dextrose, saccharin, aspartame,sucrulose, ascorbate, multivalent cation and citrate. In someembodiments, the taste masking agent concentration is from 0.01 mM toabout 50 mM in about 0.01 mM increments. By examples, about 0.01 mM,about 0.05 mM, about 0.1 mM, about 0.2 mM, about 0.3 mM, about 0.4 mM,about 0.5 mM, about 0.6 mM, about 0.7 mM, about 0.8 mM, about 0.9 mM,about 1 mM, about 2 mM, about 3 mM, about 4 mM, about 5 mM, about 6 mM,about 7 mM, about 8 mM, about 9 mM, about 10 mM, about 15 mM, about 20mM, about 25 mM, about 30 mM, about 35 mM, about 40 mM, about 45 mM, andabout 50 mM.

In some embodiments, the formulations described herein are filled into aprimary package. In some embodiments, primary packaging material istaken from the group consisting of glass or plastic, wherein plasticmaterials may be selected from the group consisting of low-densitypolyethylene (LDPE), high-density polypropylene (HDPP), or high-densitypolyethylene (HDPE). In some embodiments, the primary packaging consistsof a vial, syringe or ampoule. In some embodiments, the composition isprotected from light.

In some embodiments, the compositions described herein are formulatedunder or to result in conditions of reduced oxygen. In some embodiments,oxygen is reduced by sparging the formulation diluent prior to additionof the active pharmaceutical ingredient. Sparging gases may be selectedfrom the group consisting of carbon dioxide, argon or nitrogen. In someembodiments, oxygen is reduced by sparging the formulation diluent afteraddition of the active pharmaceutical ingredient. Sparging gases may beselected from the group consisting of carbon dioxide, argon or nitrogen.In some embodiments, oxygen exposure is reduced by replacing the ambientgas headspace of the formulation container with an inert gas. Inertgases may be selected from the group consisting of argon or nitrogen.

In some embodiments, oxygen exposure is reduced by replacing the ambientgas headspace of the primary packaging container with an inert gas.Inert gases may be selected from the group consisting of argon ornitrogen.

In some embodiments, oxygen exposure is reduced by inserting the primarypackaging into a gas-impermeable secondary packaging container.

In some embodiments, oxygen exposure is reduced by replacing the ambientgas headspace of the secondary packaging with an inert gas. Inert gasesmay be selected from the group consisting of argon or nitrogen.

In some embodiments, the aerosol for delivery to the lungs of a mammaldescribed herein contains a fine particle fraction between 10 and 100%with increment units of 1%. By example, about 10%, about 15%, about 20%,about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%,about 90%, about 95%, and about 100%. In some embodiments, the fineparticle dose is between about 0.1 mg to about 360 mgs prifenidone orpyridone analog, in 0.1 mg increments. By example, about 0.1 mg, about0.5 mg, about 1 mg, about 2 mg, about 3 mg, about 4 mg, about 5 mg,about 6 mg, about 7 mg, about 8 mg, about 9 mg, about 10 mg, about 11mg, about 12 mg, about 13 mg, about 14 mg, about 15 mg, about 16 mg,about 17 mg, about 18 mg, about 19 mg, about 20 mg, about 25 mg, about30 mg, about 35 mg, about 40 mg, about 45 mg, about 50 mg, about 60 mg,about 70 mg, about 80 mg, about 90 mg, about 100 mg, about 150 mg, about200 mg, about 220 mg, about 240 mg, about 260 mg, about 280 mg, about300 mg, about 320 mg, about 340 mg, or about 360 mg.

In some embodiments, the compositions further comprise a mucolytic agentsuitable for pulmonary delivery. In some embodiments, the compositionsfurther comprise a second anti-fibrotic agent suitable for pulmonarydelivery. In some embodiments, the compositions further comprise asecond anti-inflammatory agent suitable for pulmonary delivery.

These and other aspects of the invention will be evident upon referenceto the following detailed description. All of the U.S. patents, U.S.patent application publications, U.S. patent applications, foreignpatents, foreign patent applications and non-patent publicationsreferred to in this specification, are incorporated herein by referencein their entirety, as if each was incorporated individually. Aspects ofthe invention can be modified, if necessary, to employ concepts of thevarious patents, applications and publications to provide yet furtherembodiments of the invention.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 shows a modeled nebulized aerosol administration of pirfenidoneand oral administration of pirfenidone to a human subject. Modelincorporates scaled pharmacokinetics from Example 6.

FIG. 2. Modeled Nebulized Aerosol Administration to a Human—50 mcg/gramtarget lung tissue Cmax and correlated lung tissue and plasmapharmacokinetics. Model incorporates scaled pharmacokinetics fromExamples 6 and 7.

FIG. 3. Hydroxyproline results from bleomycin model of pulmonaryfibrosis. Demonstrates pirfenidone U-shaped dose response. Alsoindicates that small dose, direct-lung aerosol delivery enablespirfenidone anti-fibrotic efficacy within limitations of theAUC-dependent, U-shaped dose response. Hydroxyrproline delta values wereobtained by first subtracting sham results, and then subtracting thatvalue from the bleomycin-only control. Obtained p-values: #=0.012 (samelung Cmax), *=0.084 (same lung Cmax), and 1=0.075 (same plasma AUC); a.Trivdei et al, Nanotechnology. 23(50):505101, 2012.

FIG. 4. Histopathology (fibrosis score) results from bleomycin model ofpulmonary fibrosis. Demonstrates pirfenidone U-shaped dose response.Also indicates that small dose, direct-lung aerosol delivery enablespirfenidone anti-fibrotic efficacy within limitations of theAUC-dependent, U-shaped dose response. Fibrosis score delta values wereobtained by first subtracting sham results, and then subtracting thatvalue from the bleomycin-only control. Obtained p-values: #=0.007 (samelung Cmax), *=0.042 (same lung Cmax), and 4=0.143 (same plasma AUC).

FIG. 5. Modeled human inhaled aerosol pirfenidone pharmacokinetics.Demonstrates that aerosol inhalation enables a broad pirfenidonetherapeutic range within the limitations of the pirfenidone U-shapeddose response. Model incorporates scaled pharmacokinetics from Example8. Inhalation offers a broad therapeutic range within limitations of thepirfenidone U-shaped dose response. Compared to the 801 mg oralpirfenidone dose (taken with food; Rubino et al., Pulm Pharmacol Ther.22(4):279-85, 2009), a 120 mg pirfenidone RDD inhaled over 5 minutesresults in an equivalent plasma AUC and 43-fold greater lung tissueCmax; a 50 mg pirfenidone RDD inhaled over 5 minutes results in a2.4-fold lower plasma AUC and 18-fold greater lung tissue Cmax; and a2.5 mg pirfenidone RDD inhaled over 1 minute results in a 50-fold lowerplasma AUC and equivalent lung tissue Cmax. Upper panel insetillustrates pirfenidone pharmacokinetics between 0-10 mcg/gram humanlung tissue pirfenidone and 0-4 hours.

DETAILED DESCRIPTION

A number of undesirable pulmonary diseases such as interstitial lungdisease (ILD; and sub-class diseases therein), chronic obstructivepulmonary disease (COPD; and sub-class diseases therein), asthma, andfibrotic indications of the lungs, kidney, heart and eye, are initiatedfrom an external challenge. By non-limiting example, these effectors caninclude infection, cigarette smoking, environmental exposure, radiationexposure, surgical procedures and transplant rejection. However, othercauses related to genetic disposition and the effects of aging may alsobe attributed.

In epithelium, scarring serves a valuable healing role following injury.However, epithelium tissue may become progressively scarred followingmore chronic and or repeated injuries resulting in abnormal function. Inthe case of idiopathic pulmonary fibrosis (IPF; and other subclasses ofILD), if a sufficient proportion of the lung becomes scarred respiratoryfailure can occur. In any case, progressive scarring may result from arecurrent series of insults to different regions of the organ or afailure to halt the repair process after the injury has healed. In suchcases the scarring process becomes uncontrolled and deregulated. In someforms of fibrosing disease scarring remains localized to a limitedregion, but in others it can affect a more diffuse and extensive arearesulting in direct or associated organ failure.

In neurologic disease, inflammatory destruction of myelin (demylination)is considered the initial event in diseases such as multiple sclerosis.Demyelination causes scarring and hardening (sclerosis) of nerve tissuein the spinal cord, brain, and optic nerves. Demyelination slowsconduction of nerve impulses, which results in weakness, numbness, pain,and vision loss.

In epithelial injury, epithelial cells are triggered to release severalpro-fibrotic mediators, including the potent fibroblast growth factorstransforming growth factor-beta (TGF-beta), tumor necrosis factor (TNF),endothelin, cytokines, metalloproteinases and the coagulation mediatortissue factor. Importantly, the triggered epithelial cell becomesvulnerable to apoptosis, and together with an apparent inability torestore the epithelial cell layer are the most fundamental abnormalitiesin fibrotic disease. In the case of demylination, abnormal TNFexpression or activity is considered a primary cause of multiplesclerosis and other neurologic disorders, such as rheumatoid disease.

In conditions such as pulmonary, kidney, cardiac and ocular fibrosis,multiple sclerosis and rheumatoid disease, physiological responsescharacterized by control of pro-inflammatory and pro-fibrotic factorswith pyridone analogs, such as pirfenidone may be beneficial toattenuate and/or reverse fibrosis and demyelination. Therapeuticstrategies exploiting such pyridone analog and/or pirfenidone effects inthese and other indications are contemplated herein.

TNF-alpha is expressed in asthmatic airways and may play a key role inamplifying asthmatic inflammation through the activation of NF-kappaB,AP-1 and other transcription factors. IgE receptor activation inducesTNF-alpha release from human lung tissue and upregulates eosinophil TNFmRNA levels. TNF-alpha causes transient bronchial hyper-responsivenesslikely through a muscarinic receptor expression-mediated response.

TNF-alpha is also believed to play a central role in the pathophysiologyof COPD. It is produced by alveolar macrophages, neutrophils, T cells,mast cells and epithelial cells following contact with differentpollutants including cigarette smoke. TNF-alpha has been shown in animalmodels to induce pathological features associated with COPD, such as aninflammatory cell infiltrate into the lungs, pulmonary fibrosis andemphysema. Intriguingly, TNF-alpha levels in sputum increasesignificantly during acute exacerbations of COPD.

The mechanism of action for pyridone analogs, such as pirfenidone isbelieved to be both anti-inflammatory and anti-fibrotic. Pirfenidoneinhibits synthesis and release of pro-inflammatory cytokines and reducesthe accumulation of inflammatory cells in response to various stimuli.Pirfenidone also attenuates fibroblast proliferation, production offibrosis associated proteins and cytokines, and the increasedbiosynthesis and accumulation of extracellular matrix in response tocytokine growth factors such as TGF-beta and platelet-derived growthfactor (PDGF).

In in vitro cell-based assays, pirfenidone suppressed the proliferationof fibroblasts; inhibited lipopolysaccharide (LPS)-stimulated release ofPDGF, tumor necrosis factor alpha (TNF-alpha), and TGF-beta1; andinhibited collagen synthesis. Depending on the assay conditions, thesein vitro activities were evident at pirfenidone concentrations of about30 microM to about 10 mM (about 5.5 mcg/mL to about 1.85 mg/mL). Giventhat the oral Cmax of pirfenidone in IPF patients is about 42 microM inthe recommended fed-state to about 84 microM in the fasting-state (orabout 7.9 mcg/mL to about 15.7 mcg/mL, respectively), these sameactivities may be promoted in vivo, albeit in the lower range ofobserved efficacy.

Oral administration of pirfenidone to LPS-challenged mice resulted indose-dependent decreased mortality, reduced serum levels of thepro-inflammatory cytokines TNF-alpha, interleukin (IL-12) and interferongamma, and increased serum levels of the anti-inflammatory cytokine,IL-10. Pirfenidone treatment also prevented LPS-related hemorrhagicnecrosis and apoptosis in the liver, and suppressed increases inTGF-beta.

In vitro studies suggest that pirfenidone may also suppress fibrogenesisthrough selective inhibition of p38 mitogen-activated protein kinase(MAPK). These observations have been associated with an attenuation ofTGF-beta-induced collagen synthesis. The parallel observation thatsilencing p38 may also restore sensitivity to coriticosteroids in COPDis also promising for this and other disease populations. Unfortunately,compounds that inhibit p38 MAPK have also proven toxic and have beenwithdrawn from the clinical setting. These compounds have each employedoral administration.

In rat, hamster, and mouse models of bleomycin-induced lung fibrosis,prophylactic administration of pirfenidone reduced pulmonary fibrosisassessed by both histopathological analysis and quantitativedetermination of collagen content. Pirfenidone treatment also reducedpulmonary edema and pulmonary levels of TGF-beta, basic fibroblastgrowth factor (bFGF), and various pro-inflammatory cytokines.

In rat, pirfenidone decreased collagen production and deposition inhepatic fibrosis, reversed cardiac and renal fibrosis, and attenuatedthe increase in diastolic stiffness of diabetic hearts fromstreptozotocin-treated animals without normalizing cardiac contractilityor renal function. In DOCA-salt hypertensive rats, pirfenidone alsoreversed and prevented cardiac remodeling, and reversed and preventedincreased cardiac stiffness without reversing the increased vascularresponses to noradrenaline.

Human studies have shown some clinical anti-inflammatory andanti-fibrotic benefit of oral pirfenidone. Phototoxicity,gastrointestinal disorders and abnormal liver function test values mayresult in human populations following oral administration ofpirfenidone. As a consequence patient dosing must be closely monitored.In Phase 3 clinical studies with orally administered pirfenidone,initial dose escalation was required to establish gastrointestinaltolerance. However, dose levels are also limited during or followingescalation due to occurrence of nausea, rash, dyspepsia, dizziness,vomiting, photosensitivity reaction, anorexia, and elevated AST and ALTserum transaminases. In some cases, oral administration of pirfendionemay result in dose de-escalation or discontinuation of pirfenidoneadministration.

In addition to required pirfenidone dose escalation to establishgastrointestinal tolerance, dose de-escalation and the use of food hasbeen employed to enable oral administration to individuals unable toachieve tolerance and would otherwise be removed from therapy, forexample, dose de-escalation of up to and greater than 50%. Further,clinical studies utilizing the use of food to enable dose tolerabilitymay also be attempted. In both cases, the plasma Cmax is reduceddose-proportionately. More specifically, the fed-state results in abouta 50% reduction in Cmax, about a seven-fold increase in Tmax and areduction in overall exposure of 10-15%. Both fed and fasted stateresulted in a plasma half-life of about 2.5 hours. While this approachmay reduce gastrointestinal-related adverse events, the lack ofclinically-significant efficacy in recent orally-administered clinicalstudies may have been influenced by these approaches.

Based upon clinical observations and adverse events as well as observedtoxicities, oral pirfenidone therapy is limited to doses up to about1800 mg/day to about 2400 mg/day (from 600 mg TID or 801 mg TID,respectively). Thus, while pirfenidone exhibits a wide range ofnon-human efficacy, human adverse events and toxicities have limitedoral dosing to the lower end of this range.

Regulatory risk-benefit analysis between observed efficacy andassociated adverse events of orally administered pirfendione has led toconcerns that these doses do not provide sufficient efficacy to warrantthe safety risk; even in a terminal population of unmet clinical need.Provided herein in certain embodiments, is a method of administering anequivalent or increased pirfenidone or pyridone analog dose directly tothe disease site (e.g., inhalation delivery to the lung) would provideequivalent or improved efficacy over oral routes. In certainembodiments, these doses require less administered drug. In certainembodiments, this approach of administering pirfenidone by inhalationmay also benefit from reduced systemic exposure and an increased safetymargin when compared to oral administration of pirfenidone. Describedherein are compositions of pirfenidone or a pyridone analog compoundthat are suitable for delivery to a mammal by inhalation and methods ofusing such compositions.

It is unclear from the existing data whether pirfenidoneanti-inflammatory or anti-fibrotic mechanism or mechanisms of action aredriven by Cmax or exposure (area under the curve, AUC). In someembodiments, low to moderately-observed clinical efficacy may beassociated with pirfenidone plasma levels about or greater than 5mcg/mL, exposures (AUC0-infinity) about or greater than 50 mg·hr/L,and/or a plasma elimination rate of about 2.5 hours.

In some embodiments, intravenous or oral administration of pirfenidonemay result in lung epithelial lining fluid (ELF) levels comparable tothat observed in plasma, and thus, in some embodiments,clinically-measured plasma Cmax of about or greater than 5 mcg/mL aredirectly associated with low to moderately-observed clinical pulmonaryefficacy. In some embodiments, plasma levels of pirfendione resultingfrom oral administration are associated with lower efficacy, and thus issome embodiments the resultant ELF and lung tissue levels are alsoassociated with lower efficacy. In other embodiments, intravenous ororal administration of pirfenidone may result in lung epithelial liningfluid (ELF) levels less than that observed as efficacious from theplasma. In some embodiments, ELF levels corresponding with oral orintravenous-delivered, plasma-observed efficacious levels may be 0.1mcg/mL to about 5 mcg/mL. In some embodiments, ELF levels correspondingwith plasma-observed efficacious levels may be 0.1 mcg/mL to about 1mcg/mL. In some embodiments, ELF levels corresponding with oral orintravenous-delivered, plasma-observed efficacious levels may be 0.5mcg/mL to about 5 mcg/mL. In some embodiments, ELF levels correspondingwith oral or intravenous-delivered, plasma-observed efficacious levelsmay be 0.3 mcg/mL to about 3 mcg/mL. In some embodiments, directadministration of pirfenidone to the lung, results in delivery of aboutor greater than 5 mcg pirfenidone to one mL ELF, and may result inequivalent pulmonary efficacy without elevated systemic levelsassociated with adverse events and toxicities observed withadministration. By non-limiting example, this may be accomplished byoral or intranasal inhaled delivery of aerosolized pirfenidone orpyridone analog to the lung providing about or greater than 0.1 mcg/mL,for example greater than about 0.2 mcg/mL, 0.4 mcg/mL, 0.6 mcg/mL, 0.8mcg/mL, 1.0 mcg/mL, 2 mcg/mL, 3 mcg/mL, 4 mcg/mL, 5 mcg/mL, 6 mcg/mL, 7mcg/mL, 8 mcg/mL, 9 mcg/mL, or greater than 10 mcg/mL of pirfenidone orpyridone analog to the ELF. Once in the ELF, pirfenidone or pyridoneanalog will in some embodiments penetrate lung tissue resulting inbetween about 0.004 mcg and 0.7 mcg pirfenidone or pyridone analog toone gram lung tissue (about 0.1 mcg/mL in about 25 mL ELF to about 5mcg/mL in about 75 mL ELF, about 600 grams adult human lung tissueweight).

In some embodiments, pirfenidone may readily equilibrate between theplasma and lung, and/or other organs. In some embodiments, organpirfenidone levels may also mimic that of plasma, such as for example,the lung, heart, kidney or nervous system. In some embodiments, deliveryof about or greater than 0.004 mcg to 0.7 mcg pirfenidone to one gramtissue may provide a similar therapeutic benefit to other organs. Insome embodiments, providing additional pirfenidone or pyridone analogmay provide additional efficacy. In some embodiments, this may beaccomplished by inhalation (i.e. oral inhalation or intranasalinhalation) delivery of aerosolized pirfenidone or pyridone analog tothe lung. In some embodiments, pirfenidone or pyridone analog deliveredto the lung may, in some embodiments, become readily available to theheart. In some embodiments, providing about 0.1 mcg/mL to about 5 mcg/mLELF or 0.004 mcg/gram to about 0.7 mcg/gram lung tissue pirfenidone orpyridone analog pyridone analog to the ELF or 0.2 to 0.7 mcg/gram lungtissue pirfenidone or pyridine analog may result in a similarefficacious dose to the heart in the absence of elevated systemicadverse events or toxicities observed with oral dosing. In someembodiments, intranasal inhalation or oral inhalation delivery ofaerosolized pirfenidone or pyridone analog to the lung may result inefficacious delivery of pirfenidone or pyridone analog to the liver. Insome embodiments, pirfenidone or pyridone analog delivered to the lungwill become available to the liver. In some embodiments, providing about0.1 mcg/mL to about 5 mcg/mL ELF or 0.004 mcg/gram to about 0.7 mcg/gramlung tissue pirfenidone or pyridone analog pyridone analog may result ina similar efficacious dose to the liver in the absence of elevatedsystemic adverse events or toxicities observed with oral dosing. In someembodiments, intranasal or oral inhalation delivery of aerosolizedpirfenidone or pyridone analog to the lung may result in efficaciousdelivery of pirfenidone or pyridone analog to the kidney. In someembodiments, pirfenidone or pyridone analog delivered to the lung willbecome available to the kidney. In some embodiments, providing about 0.1mcg/mL to about 5 mcg/mL ELF or 0.004 mcg/gram to about 0.7 mcg/gramlung tissue pirfenidone or pyridone analog pyridone analog may result ina similar efficacious dose to the kidney in the absence of elevatedsystemic adverse events or toxicities observed with oral dosing. In someembodiments, intranasal inhalation delivery of aerosolized pirfenidoneor pyridone analog to the nasal cavity may result in efficaciousdelivery of pirfenidone or pyridone analog to the central nervous system(CNS). In some embodiments, inhalation delivery of pirfenidone orpyridone analog to the nasal cavity will become readily available to theCNS. In some embodiments, providing a nasal cavity-delivered doseequivalent to about 0.1 mcg/mL to about 5 mcg/mL ELF or 0.004 mcg/gramto about 0.7 mcg/gram lung tissue pirfenidone or pyridone analog mayresult in similar efficacy in the CNS in the absence elevated systemicadverse events or toxicities observed with oral dosing.

In some embodiments, topical delivery of aerosolized, liquid or creampirfenidone or pyridone analog to a site of desired effect providingabout 0.004 mcg/gram to about 0.7 mcg/gram tissue weight may result in asimilar efficacious dose in the absence of systemic adverse events ortoxicities. In some embodiments, topical delivery of aerosolized, liquidor cream pirfenidone or pyridone analog to damaged skin epithelium mayprevent or reverse scarring, fibrosis and/or inflammation. This damagecould be the result of infection, burn, surgery, acute of chronic injury(such as bed soars), or other event. In some embodiments, topicaldelivery of liquid or dry powder pirfenidone or pyridone analog to thebladder may prevent scarring, fibrosis and/or inflammation associatedwith bladder infection, bladder cancer, in-dwelling catheter or otherevent. In some embodiments, topical delivery of liquid pirfenidone orpyridone analog to the eye may prevent development of post-operativefibrosis in the conjunctiva and/or episclera following glaucoma surgery.

In some embodiments, injection delivery of liquid pirfenidone orpyridone analog to a site of desired effect providing about 0.004mcg/gram to about 0.7 mcg/gram tissue weight pirfenidone or pyridoneanalog may result in a similar efficacious dose in the absence ofsystemic adverse events or toxicities. In some embodiments, injectiondelivery of liquid pirfenidone or pyridone analog to skeletal joints mayprevent scarring, fibrosis and/or inflammation associated withautoimmune diseases, arthritis, rheumatoid arthritis, infection or otherevent.

In some embodiments, in addition to Cmax, and in additional embodiments,pirfenidone exposure (AUC) to the disease site may also be critical forefficacy. In some embodiments, plasma AUC0-infinity about or greaterthan 50 mg·hr/L is also associated with pulmonary efficacy. In someembodiments, partial or ready equilibrium of pirfenidone between theplasma and lung ELF and between the plasma and lung tissue, in someembodiments, may provide that AUC may also be mimicked in the lung. Inother embodiments, lung ELF and tissue AUC may be less.

In some embodiments, individually or in combination Cmax, AUC and/orhalf-life are required for efficacy, and thus in some embodiments areprovided a conservative model with all three parameters (Cmax, AUC andhalf-life) required for efficacy. In some embodiments, and bynon-limiting example, direct inhalation delivery of about 0.1 mcg toabout 5 mcg pirfenidone or pyridone analog to one mL lung ELF, providingan ELF AUC0-infinity about 1.0 mg·hr/L or about 50 mg·hr/L, andmaintaining these levels for the same period of time as that deliveredvia the oral route are equivalently efficacious. Similarly, in otherembodiments, direct inhalation delivery of about or greater than 0.2004to 0.7 mcg pirfenidone or pyridone analog to one gram lung tissue,provides a tissue AUC0-infinity less than to equivalent or substantiallyequivalent to that of the plasma following oral delivery, and in furtherembodiments, maintaining these levels for the same period of time asthat delivered via the oral route is equivalently efficacious. In someembodiments, the following assumptions and theoretical calculations aredescribed for inhalation therapy:

-   -   ELF Delivery Assumptions:    -   1. The total volume of human ELF is 25 mL;    -   2. The inhaled route of administration is dependent upon a        respirable delivered dose (RDD); RDD is the fraction of drug        inhaled in aerosol particles less than 5 microns in diameter;    -   3. RDD of typical dry powder, liquid nebulization or meter-dose        inhalation devices ranges from 10% to 70%. In some embodiments,        higher and lower efficiency devices with RDDs greater than 70%        and less than 10% are contemplated.    -   4. Plasma pirfenidone or pyridone analog half-life following        oral administration is around 2.5 hours. In some embodiments,        intestinal absorption affects this vule but for exemplary        purposes of this model the lung ELF pirfenidone half-life        following inhalation delivery is assumed to be one-half that        following oral administration (e.g. 2.5 hours/2=1.25 hours).        Half-life values may be supported by measurements indicating        intravenous administration of pirfenidone results in a lung ELF        half-life of around one-half that following oral administration;    -   5. In some embodiments, a lung ELF level of 5 mcg/mL may be the        lower limit of efficacy; and    -   6. 801 mg oral pirfenidone results in a plasma level at or        greater than 5 mcg/mL for 4 hours (human-measured value). For        purposes of comparing routes, this model will assume lung ELF        pirfenidone levels following oral administration remain at or        above 5 mcg/mL lung ELF for the same duration as plasma.

Exemplary ELF Calculations:

-   -   1. Mcg pirfenidone delivered to 25 mL ELF to make 5 mcg/mL=125        mcg;    -   2. Based upon an RDD efficiency of 30%, the unit dose required        is 416 mcg (125 mcg/0.3=416 mcg);    -   3. Based upon an RDD efficiency of 50%, the unit dose required        is 250 mcg (125 mcg/0.5=250 mcg);    -   4. Based upon an RDD efficiency of 70%, the unit dose required        is 179 mcg (125 mcg/0.7=179 mcg); and

Compensating to maintain at or above these levels for 3.2 half lives of1.25 hours each (4 hours at or above 5 mcg/mL with a lung half-life of1.25 hours=3.2 half lives):

-   -   5. For an RDD efficiency of 30%, the unit dose required to        maintain the lower limit of clinically-observed efficacy (in        this case 416 mcg) for 3.2 half lives is 3994 mcg;    -   6. For an RDD efficiency of 50%, the unit dose required to        maintain the lower limit of clinically-observed efficacy (in        this case 250 mcg) for 3.2 half lives 2400 mcg; and    -   7. For an RDD efficiency of 70%, the unit dose required to        maintain the lower limit of clinically-observed efficacy (in        this case 179 mcg) for 3.2 half lives 1718 mcg.

By non-limiting example, based upon the above assumptions and in certainembodiments, a dose of approximately 4 mg in a device deliveringpirfenidone or pyridone analog with 30% efficiency may result in lungELF levels at or above 5 mcg/mL for the same duration as that obtainedfollowing 801 mg administered orally. Moreover, while the minimallyefficacious pirfenidone dose may be maintained for this duration, localpirfenidone levels may also exhibit significantly higher ELF Cmax levelsproviding improved efficacy. In some embodiments, delivery of 4 mgpirfenidone or pyridone analog with a 30% efficiency device may resultin a lung ELF Cmax up to about 48 mcg/mL (4 mg×30%=1.2 mg. 1.2 mg/25 mLELF=48 mcg/mL). In some embodiments, based upon the above assumptions adose of approximately 66 mg in a device delivering pirfenidone orpyridone analog with 70% efficiency may result in a lung ELF Cmax up to1.85 mg/mL (66 mg×70%=46.2 mg. 46.2 mg/25 mL ELF=1.85 mg/mL). In someembodiments, based upon the above assumptions a dose of approximately154 mg in a device delivering pirfenidone or pyridone analog with 30%efficiency may also result in a lung ELF Cmax up to 1.85 mg/mL (154mg×30%=46.2 mg. 46.2 mg/25 mL ELF=1.85 mg/mL). In some embodiments,based upon the above assumptions a dose of approximately 12 mg in adevice delivering pirfenidone or pyridone analog with 70% efficiency mayresult in a lung ELF Cmax up to 336 mcg/mL (12 mg×70%=8.4 mg. 8.4 mg/25mL ELF=336 mcg/mL). In some embodiments, based upon the aboveassumptions a dose of approximately 28 mg in a device deliveringpirfenidone or pyridone analog with 30% efficiency may also result in alung ELF Cmax up to 336 mcg/mL (28 mg×30%=8.4 mg. 8.4 mg/25 mL ELF=336mcg/mL). In some embodiments, this dose may result in maintaining at orabove the 5 mcg/mL minimally efficacious dose for about 6 half-lifes, orabout 15 hours. In some embodiments, the embodiments described forinhalation therapy provide beneficial efficacy through an increased Cmaxand maintaining drug exposure at or above the 5 mcg/mL minimal efficacyrange for a longer duration than that currently limited by oral dosing.In some embodiments, prolonged exposure may enable a reduced dosinginterval (by example once-a-day or twice-a-day versus the current threetimes a day oral dosing regimen). In some embodiments, while delivery isdirectly to the lung, these doses may result in very low systemic plasmalevels (e.g. around 2 mcg/mL pirfenidone). In some embodiments, althoughabout 28 mg pirfenidone or pyridone analog delivered with a 30%efficiency aerosol device may initially result in elevated levels invasculature and tissues immediately downstream of the lung (or nasalcavity), the dilute systemic plasma concentration may be around 1.7mcg/mL (28 mg×30%=8.4 mg. 8.4 mg/5 L total body blood=1.7 mcg/mL). Insome embodiments, delivery of about 46 mg pirfenidone or pyridone analogmay result in a dilute systemic plasma concentration of about 9.3mcg/mL.

One of skill in the art will recognize from the discussions herein thatdoses calculated in the above model will change if the actual measuredlung ELF half-life of pirfenidone or pyridone analog eliminationchanges. If the half-life is shorter, more administered pirfenidone orpyridone analog will be required to maintain the lung ELF concentrationabove that considered the minimal efficacious level. Additionalincreases in administered pirfenidone or pyridone analog may be desiredto further improve efficacy. Further, in addition to delivering desiredlung tissue Cmax and AUC, oral inhaled or intranasal inhaled delivery ofaerosol pirfenidone or pyridone analog may also serve an efficient routefor systemic delivery. In some embodiments, dosing schemes arecontemplated that enable inhaled delivery of pirfenidone or pyridoneanalog to initially achieve desired lung tissue Cmax and AUC, withplasma half-life slower than that of the lung ELF, and targeting thedelivery of specific plasma concentrations may in turn prolong lungELF-pirfenidone or pyridone analog exposure.

-   -   Exemplary Lung Tissue Delivery Assumptions:    -   1. The total wet weight of the adult human lung is about 685 to        1,050 grams (for calculations, conservatively about 1,000        grams);    -   2. The adult human lung blood volume is about 450 mL;    -   3. The tissue weight of the adult human lung is conservatively        1,050 grams wet weight minus 450 mL blood weight (assuming        density of 1.0), equals 600 grams;    -   4. In some embodiments, following intravenous push of        pirfenidone to a mouse:        -   plasma pirfenidone Tmax is equivalent to lung Tmax        -   40 mg/kg intravenous dose results in plasma Cmax of about 55            mcg/mL and a lung Cmax of 30 mcg/gram wet tissue        -   Conservatively, blood makes up about 40% of the wet lung            weight. Given that the plasma and lung Tmax are, in some            embodiments, equivalent, it follows that much of the 30            mcg/g pirfenidone measured in the wet lung is due to the            presence of blood. Conservatively, if blood makes up about            40% of the wet lung weight, then 40% of the plasma Cmax (or            55 mcg/mL×40%) is about 22 mcg/gram pirfenidone in the            measured lung weight is due to blood. Taking the difference            between the wet lung Cmax and this number (or 30 mcg/g minus            22 mcg/g), about 8 mcg/g is in the lung tissue.        -   a measured wet lung half-life that is about 45% longer than            the plasma half-life may be considered. Taking the argument            above that about 40% of the wet lung pirfenidone is in the            blood, the actual lung tissue half-life is much greater then            45% longer than plasma;    -   5. From the above observations and calculations that 55 mcg/mL        plasma Cmax results in a lung tissue Cmax of about 8 mcg/gram,        the following comparison to humans can be made:        -   Taking an early assumption, the lower end of human efficacy            is 5 mcg/mL plasma pirfenidone.        -   Assuming the above ratio (55 mcg/mL plasma results in 8            mcg/gram lung tissue) is true for humans, 5 mcg/mL divided            by 55 mcg/mL is about 9.1%. 9.1% of 8 mcg/gram is about 0.7            mcg/gram.        -   Taken together, 5 mcg/mL plasma pirfenidone may result in            0.7 mcg/gram lung tissue pirfenidone. Thus, about 0.7            mcg/gram lung tissue pirfenidone is the lower end of            efficacy.    -   6. The inhaled route of administration is dependent upon a        respirable delivered dose (RDD). The RDD is the fraction of drug        inhaled in aerosol particles less than 5 microns in diameter;    -   7. RDD of typical dry powder, liquid nebulization or meter-dose        inhalation devices ranges from 10% to 70%. Higher and lower        efficiency devices with RDDs greater than 70% and less than 10%        also exist;    -   8. As discussed above, lung tissue pirfenidone half-life is much        longer than the intravenously delivered plasma pirfenidone        half-life (by as much or greater than 2-4×). Plasma pirfenidone        half-life following oral administration is around 2.5 hours.        However, continued intestinal absorption affects this number and        hence is much longer than that following intravenous delivery.        Therefore, for purposes of this model the lung tissue        pirfenidone half-life following inhalation delivery will be        considered equivalent to that following oral administration        (e.g. 2.5 hours);    -   9. From the above observations and calculations, the lower limit        of efficacy in lung tissue is 8 mcg/gram; and    -   10. Incorporating that 801 mg oral pirfenidone results in a        human plasma level at or greater than 5 mcg/mL for 4 hours and        that 5 mcg/mL plasma results in 0.7 mcg/gram lung tissue        pirfenidone, what is delivered by oral or intranasal inhalation        must be at or above 0.7 mcg/gram lung tissue pirfenidone for at        least 4 hours for equivalent lung fibrosis efficacy to the oral        dose.    -   Exemplary Lung Tissue Calculations:    -   1. Mcg pirfenidone delivered to 1000 grams wet lung tissue        (blood plus lung tissue) to make 0.7 mcg/gram=700 mcg;    -   2. Based upon an RDD efficiency of 30%, the unit dose required        is 2,333 mcg (700 mcg/0.3=2,333 mcg);    -   3. Based upon an RDD efficiency of 50%, the unit dose required        is 1,400 mcg (700 mcg/0.5=1,400 mcg);    -   4. Based upon an RDD efficiency of 70%, the unit dose required        is 1,000 mcg (700 mcg/0.7=1,000 mcg); and    -   Compensating to maintain at or above these levels for 2 half        lives of 2.5 hours each (4 hours at or above 0.7 mcg/gram wet        lung tissue with a lung half-life of 2.5 hours=1.6 half lives):    -   5. For an RDD efficiency of 30%, the unit dose required to match        the lower limit of clinically-observed oral route efficacy (in        this case 2,333 mcg) for 1.6 half lives is 3,733 mcg;    -   6. For an RDD efficiency of 50%, the unit dose required to match        the lower limit of clinically-observed oral route efficacy (in        this case 1,400 mcg) for 1.6 half lives 2,240 mcg; and    -   7. For an RDD efficiency of 70%, the unit dose required to match        the lower limit of clinically-observed oral route efficacy (in        this case 1,000 mcg) for 1.6 half lives 1,600 mcg.

By non-limiting example, based upon the above assumptions a dose ofapproximately 3.7 mg in a device delivering pirfenidone or pyridoneanalog with 30% efficiency may result in wet lung tissue levels at orabove 0.7 mcg/gram for the same duration as that obtained following 801mg administered orally. Moreover, while the minimally efficaciouspirfenidone dose is maintained for this duration, local pirfenidonelevels may exhibit significantly higher wet lung tissue Cmax levelsproviding improved efficacy. By non-limiting example, delivery of 3.7 mgpirfenidone or pyridone analog with a 30% efficiency device may resultin a wet lung tissue Cmax up to about 1.1 mcg/gram (3.7 mg×30%=1.1 mg.1.1 mg/1,050 grams wet lung weight=1.1 mcg/gram). This number is nearabout 1.5-fold higher than that delivered following oral delivery. Byanother non-limiting example, based upon the above assumptions a dose ofapproximately 50 mg in a device delivering pirfenidone or pyridoneanalog with 30% efficiency may result in a wet lung tissue Cmax up to14.3 mcg/mL (50 mg×30%=15 mg. 15 mg/1,050 grams wet lung weight=14.3mcg/gram), or about 20-fold higher than that delivered following oraldelivery. Under this scenario, this dose may result in maintaining at orabove the 0.7 mcg/gram wet lung tissue minimally efficacious dose for atleast about 5 half-lifes, or about 12.5 hours; compared to 4 hoursfollowing 801 mg oral dose administration. Similarly, by anothernon-limiting example, based upon the above assumptions a dose ofapproximately 15 mg in a device delivering pirfenidone or pyridoneanalog with 70% efficiency may result in a wet lung tissue Cmax up to 10mcg/mL (15 mg×70%=10.5 mg. 10.5 mg/1,050 grams wet lung weight=10mcg/gram), or about 14-fold higher than that delivered following oraldelivery. Under this scenario, this dose may result in maintaining at orabove the 0.7 mcg/gram wet lung tissue minimally efficacious dose forabout 4.5 half-lifes, or at least about 11 hours; compared to 4 hoursfollowing 801 mg oral dose administration. Such duration over 0.7mcg/gram lung tissue may permit twice a day dosing (BID). Similarly, byanother non-limiting example, based upon the above assumptions a dose ofapproximately 75 mg in a device delivering pirfenidone or pyridoneanalog with 70% efficiency may result in a wet lung tissue Cmax up to 50mcg/mL (75 mg×70%=52.5 mg. 52.5 mg/1,050 grams wet lung weight=50mcg/gram), or about 71-fold higher than that delivered following oraldelivery. Under this scenario, this dose may result in maintaining at orabove the 0.7 mcg/gram wet lung tissue minimally efficacious dose for atleast about 6 half-lifes, or about 15 hours; compared to 4 hoursfollowing 801 mg oral dose administration. Such duration over 0.7mcg/gram lung tissue may permit BID dosing. Similarly, by anothernon-limiting example, based upon the above assumptions a dose ofapproximately 15 mg in a device delivering pirfenidone or pyridoneanalog with 30% efficiency may result in a wet lung tissue Cmax up to4.3 mcg/mL (15 mg×30%=4.5 mg. 4.5 mg/1,050 grams wet lung weight=4.3mcg/gram), or about 6-fold higher than that delivered following oraldelivery. Under this scenario, this dose may result in maintaining at orabove the 0.7 mcg/gram wet lung tissue minimally efficacious dose for atleast about 3 half-lifes, or about 7.5 hours; compared to 4 hoursfollowing 801 mg oral dose administration. Similarly, by anothernon-limiting example, based upon the above assumptions a dose ofapproximately 75 mg in a device delivering pirfenidone or pyridoneanalog with 30% efficiency may result in a wet lung tissue Cmax up to 21mcg/mL (75 mg×30%=22.5 mg. 52.5 mg/1,050 grams wet lung weight=21mcg/gram), or about 31-fold higher than that delivered following oraldelivery. Under this scenario, this dose may result in maintaining at orabove the 0.7 mcg/gram wet lung tissue minimally efficacious dose for atleast about 5 half-lifes, or about 12.5 hours; compared to 4 hoursfollowing 801 mg oral dose administration. Such duration over 0.7mcg/gram lung tissue may permit BID dosing. Similarly, by anothernon-limiting example, based upon the above assumptions a dose ofapproximately 15 mg in a device delivering pirfenidone or pyridoneanalog with 10% efficiency may result in a wet lung tissue Cmax up to1.4 mcg/mL (15 mg×10%=1.5 mg. 1.5 mg/1,050 grams wet lung weight=1.4mcg/gram), or about 2-fold higher than that delivered following oraldelivery. Under this scenario, this dose may result in maintaining at orabove the 0.7 mcg/gram wet lung tissue minimally efficacious dose forabout 1 half-lifes, or at least about 2.5 hours; compared to 4 hoursfollowing 801 mg oral dose administration. Similarly, by anothernon-limiting example, based upon the above assumptions a dose ofapproximately 75 mg in a device delivering pirfenidone or pyridoneanalog with 10% efficiency may result in a wet lung tissue Cmax up to 21mcg/mL (75 mg×10%=7.5 mg. 7.5 mg/1,050 grams wet lung weight=7.1mcg/gram), or about 10-fold higher than that delivered following oraldelivery. Under this scenario, this dose may result in maintaining at orabove the 0.7 mcg/gram wet lung tissue minimally efficacious dose forabout 3.5 half-lifes, or at least about 8.8 hours; compared to 4 hoursfollowing 801 mg oral dose administration. Such duration over 0.7mcg/gram lung tissue may permit TID dosing. Such an approach couldbenefit efficacy through an increased Cmax and maintaining drug exposureat or above the 0.7 mcg/gram wet lung tissue minimal efficacy range fora longer duration than that currently limited by oral dosing. Suchprolonged exposure may enable a reduced dosing interval (by exampleonce-a-day or twice-a-day versus the current three times a day oraldosing regimen). Moreover, while this approach delivers directly to thelung, using the above non-limiting examples these doses may result inreduced systemic plasma levels (e.g. Cmax from less than 0.6 mcg/mLpirfenidone from a 4.5 mg delivered dose to 5,000 mL blood to less than2 mcg/mL pirfenidone from a 15 mg delivered dose to less than 10 mcg/mLfrom a 75 mg dose).

Doses calculated in the above model will change considerably if theactual measured lung tissue half-life of pirfenidone or pyridone analogelimination changes. If the half-life is faster, more inhaledpirfenidone or pyridone analog will be required to maintain the lungtissue concentration above that considered the minimal efficaciouslevel. Additional increases in inhaled pirfenidone or pyridone analogmay be desired to further improve efficacy. Further, in addition todelivering desired lung tissue Cmax and AUC, inhaled delivery of aerosolpirfenidone or pyridone analog may also serve an efficient route forsystemic delivery. In some embodiments, dosing schemes are contemplatedthat enable inhaled delivery of pirfenidone or pyridone analog toinitially achieve desired lung tissue Cmax and AUC, and as plasmahalf-life is predicted to be slower than that of the lung tissue,targeting the delivery of specific plasma concentrations may in turnprolong lung tissue-pirfenidone or pyridone analog exposure.

As scarring is irreversible, IPF efficacy is the act of protectingnative lung tissue against invading fibrosis. Therefore, maintainingregular efficacious drug levels in unaffected tissue is critical forimproved patient survival. Clinical and nonclinical studies havesuggested pirfenidone efficacy is dose-responsive ranging fromslowed-disease progression to improvement. Unfortunately, substantialgastrointestinal (GI) side effects and systemic toxicity have forced anapproved oral dose that is limited to the lower end of this range.Complicating matters, recommendations for dose-absorbing food andfrequent triggering of dose-reduction/discontinuation protocolsaddressing these issues further reduce lung dose and interrupt requiredmaintenance therapy of this otherwise promising drug. Inhalationdelivery of aerosol pirfenidone or pyridone analog directly to the lungwill reduce or eliminate these safety or tolerability limitationsassociated with the oral route of delivery.

Oral pirfenidone efficacy has been moderately demonstrated in humanclinical studies and the data suggests that this effect increases withhigher doses. Unfortunately, significant side effects and toxicity havelimited the oral dose to the lower end of this efficacy range (Esbrietapproved up to 2403 mg/d). Jeopardizing this already low efficacy dose,the Esbriet prescription requires an initial dose-escalation scheme andrecommended administration with food to acquire minimal GI tolerance andan acceptable side-effect/toxicity profile (range up to three 267 mgcapsules, or 801 mg three times a day (TID)). Unfortunately, not allpatients reach this recommended dose and food further reducesbioavailability (food reduces Cmax and AUC˜50% and ˜20%, respectively).Further, elevated liver enzyme levels and skin photoreactivity initiatea physician-guided dose-reduction and stoppage protocol that in Phase 3studies permitted up to a 50% dose reduction before discontinuation (inthese studies between 48% and 67% of patient doses were reduced). Aschronic lung tissue dosing of effective drug levels is critical formaintenance protection against invading fibrosis, it is likely that oralpirfenidone prescription and practice result in sub-efficacious dosingof this otherwise promising drug; a hypothesis that may in part explainthe moderate efficacy observed in Phase 3 studies.

For oral administration in the context of treatment of pulmonaryfibrosis high oral doses are required to achieve plasma levels requiredfor efficacious lung tissue exposure. However, gastrointestinalside-effects and systemic toxicities have limited the approved oral doseto a level restricted to the low end of the efficacy and dose-responsecurve. In one embodiment, inhaled pirfenidone or pyridone analogimproves pirfenidone treatment effectiveness through increased lung doseand improved compliance. In one embodiment, inhalation of pirfenidone orpyridone analog (e.g. with a nebulizer) delivers pirfenidone or pyridoneanalog directly to the lung and whole-body dilution of the delivereddose is minimized. In some embodiments, inhalation of pirfenidonereduces or eliminates GI exposure and/or systemic toxicities that arecommon with oral administration of pirfenidone or pyridone analog. Insome embodiments, inhalation delivery of pirfenidone or pyridone analogprovided herein provides higher lung tissue levels of pirfenidone thanis possible through oral administration. In some embodiments, inhalationdelivery of pirfenidone or pyridone analog serves as an efficient meansof delivering pirfenidone or pyridone analog to the systemiccompartment. In some embodiments, inhalation delivery of pirfenidone orpyridone analog provides Cmax and AUC benefits over the oral route. Insome embodiments, inhalation delivery of pirfenidone or pyridone analogprovides Cmax and AUC benefits over the oral route, wherein plasmare-circulated, aerosol-delivered pirfenidone or pyridone analogmaintains these beneficial properties. In some embodiments, the methodsdescribed herein may be used to treat patients diagnosed withmild-to-moderate IPF. In some embodiments, the methods described hereinmay be used to treat patients diagnosed with mild-to-severe IPF. In someembodiments, the methods described herein may be used to treat patientsdiagnosed with mild-to-moderate IPF without the need to initiallydose-escalate the patient. In some embodiments, the methods describedherein may be used to treat patients diagnosed with mild-to-severe IPFwithout the need to initially dose-escalate the patient. In someembodiments, the methods described herein may be used to treat patientsdiagnosed with mild-to-moderate IPF without the need to monitor anddose-reduce or stop therapy due to gastrointestinal, phototoxic or liverenzyme-associated adverse events. In some embodiments, the methodsdescribed herein may be used to treat patients diagnosed withmild-to-severe IPF without the need to monitor and dose-reduce or stoptherapy due to gastrointestinal, phototoxic or liver enzyme-associatedadverse events. In some embodiments, the methods described herein may beused to provide a prophylactic therapy to patients diagnosed withmild-to-moderate IPF. In some embodiments, the methods described hereinmay be used to provide a prophylactic therapy to patients diagnosed withmild-to-severe IPF. In some embodiments, the methods described hereinmay be used to provide a prophylactic therapy to patients withmild-to-moderate IPF without the need to initially dose-escalate thepatient. In some embodiments, the methods described herein may be usedprovide a prophylactic therapy to patients diagnosed with mild-to-severeIPF without the need to initially dose-escalate the patient. In someembodiments, the methods described herein may be used to provide aprophylactic therapy to patients diagnosed with mild-to-moderate IPFwithout the need to monitor and dose-reduce or stop therapy due togastrointestinal, phototoxic or liver enzyme-associated adverse events.In some embodiments, the methods described herein may be used to providea prophylactic therapy to patients diagnosed with mild-to-severe IPFwithout the need to monitor and dose-reduce or stop therapy due togastrointestinal, phototoxic or liver enzyme-associated adverse events.In some embodiments, the methods described herein may be used to slowdisease progression of patients diagnosed with mild-to-moderate IPFwithout the need to initially dose-escalate the patient. In someembodiments, the methods described herein may be used to slow diseaseprogression of patients diagnosed with mild-to-severe IPF without theneed to initially dose-escalate the patient. In some embodiments, themethods described herein may be used to slow disease progression ofpatients diagnosed with mild-to-moderate IPF without the need to monitorand dose-reduce or stop therapy due to gastrointestinal, phototoxic orliver enzyme-associated adverse events. In some embodiments, the methodsdescribed herein may be used to slow disease progression of patientsdiagnosed with mild-to-severe IPF without the need to monitor anddose-reduce or stop therapy due to gastrointestinal, phototoxic or liverenzyme-associated adverse events. By non-limiting example, clincal endpoints of IPF efficacy include reduced decline in forced vital capacity(FVC), reduced decline in distance walked over a six-minute interval(six-minute walk test; 6MWT), slowed decline in carbon monoxidediffusion capacity (DLCO), improved progression-free survival (PFS),reduced mortality and monitoring changes in biomarkers such as MMP7, andCCL18. In some embodiments, a comparison of oral and inhaled aerosolproperties that may be observed is shown in Table A.

TABLE A Advantages of inhaling pirfenidone Oral Pirfenidone InhaledPirfenidone High oral dose = minimally-effective Lower inhaled dose =superior lung levels lung levels Oral route = significant GI sideeffects Inhaled route = no/reduced GI side effects High dose = toxicityLower dose = reduced toxicity Low efficacy: High efficacy: 1.Pirfenidone is a low potency drug. 1. Inhaled route permits use ofsmaller The oral route requires a very high pirfenidone doses to deliversuperior dose to deliver sufficient lung levels. initial pirfenidonelung tissue Cmax Significant GI side effects and to a and AUC in theabsence of GI side- lesser extent systemic toxicities limit effects. Insome embodiments, inhaled the oral dose to the lower end of theadministration also serves as non-oral efficacy and dose-response curve.route for systemic delivery; enabling 2. Initial dose escalationrequired to sufficient circulating plasma obtain maximum-toleratedpirfenidone levels to extend the maintenance dose. Due to poor durationof superior efficacy. tolerability, this maintenance dose is 2. Goodtolerability permits establishing often set below the approved doselevel the maintenance dose a the approved level 3. Continuedintolerability and safety concerns 3. Strong adherence to maintenancetherapy reduce adherence to maintenance therapy Dose and chronic therapymaintained Dose reduced and interrupted Inhaled drug unaffected by foodRecommended food absorbs drug Safe & well-tolerated; no need for Sideeffects and toxicity trigger special protocols dose reduction/stoppageprotocols

In some embodiments the methods described herein provide for delivery ofhigh concentration, readily bioavailable pirfenidone or pyridone analogcompound which in turn provides improved efficacy over pirfenidone orpyridone analog compound administered by the oral route or by inhalationof a slow-dissolving or otherwise slowly bioavailable compoundformulation. In some embodiments, such slow-dissolving or otherwiseslowly bioavailable compound formulations for inhalation include, butare not limited to a dry powder formulation, a liposomal formulation, anano-suspension formulation, or a micro-suspension formulation. In someembodiments, the aqueous solutions of pirfenidone or pyridone analogdescribed and contemplated herein for administration by inhalation arecompletely homogeneous and soluble.

In some embodiments, an obstacle to patient compliance with oralpirfenidone therapy is GI intolerability. Pirfenidone blood levels mayalso be important has they have been implicated in other observedtoxicities. Thus, factors contributing to increased blood levels must beconsidered. For the oral route of administration, toxicity and GIintolerability have limited the dose to 801 mg three times a day. Whileelevated liver enzymes, photosensitivity reaction and phototoxicityoccur at this dose, they occur with higher frequency and greaterseverity with higher doses. Secondly, pirfenidone is primarilymetabolised by CYP1A2. In vitro metabolism studies with hepaticmicrosomes indicate that approximately 48% of pirfenidone is metabolisedvia CYP1A2 with other CYP isoenzymes including CYP2C9, 2C19, 2D6, and2E1 each contributing less than 13%. Thus, inhibiting these enzymesystems results in elevated pirfenidone blood levels, resulting inincreased incidence and severity of toxicity. To this end, items such asgrapefruit juice, fluvoxamine and other inhibitors of CYP1A2 should beavoided during oral treatment with pirfenidone.

Oral administration of pirfenidoen is contraindicated in patients withconcomitant use of fluvoxamine. Fluvoxamine should be discontinued priorto the initiation of Esbriet therapy and avoided during Esbriet therapydue to the reduced clearance of pirfenidone. Other therapies that areinhibitors of both CYP1A2 and one or more other CYP isoenzymes involvedin the metabolism of pirfenidone (e.g. CYP2C9, 2C19, and 2D6) shouldalso be avoided during pirfenidone treatment.

Also for the oral administration, special care should also be exercisedif CYP1A2 inhibitors are being used concomitantly with potent inhibitorsof one or more other CYP isoenzymes involved in the metabolism ofpirfenidone such as CYP2C9 (e.g amiodarone, fluconazole), 2C19 (e.g.chloramphenicol) and 2D6 (e.g. fluoxetine, paroxetine).

The oral product should be used with caution in patients treated withother moderate or strong inhibitors of CYP1A2 (e.g. ciprofloxacin,amiodarone, propafenone).

As many products effecting CYP enzymes are useful to fibrosis patients,permitting their use would be beneficial. While the oral route isalready at the maximum permissible dose (which provides only moderateefficacy), any inhibition of the enzymes described above elevatespirfenidone blood levels and increases the rate and severity of thetoxic events described herein. In some embodiments oral inhalation andintranasal inhalation delivery of pirfenidone or pyridone analogs canachieve effective tissue levels with much less drug than that requiredby the oral product, and in some embodiments result in blood levels aresignificantly lower and consequences associated with CYP enzymeinhibitory properties described herein are removed. In some embodiments,use of these CYP inhibitory enzyme products currently contraindicatedwith the oral medicine may be administered with pirfenidone or pyridoneanalog.

The primary metabolite of pirfenidone is 5-carboxy-pirfenidone.Following oral or intravenous administration, this metabolite appearsquickly at high concentrations in blood. 5-carboxy-pirfenidone does notappear to have anti-fibrotic or anti-inflammatory activity, its highblood levels occur at the loss of pirfenidone blood concentrations.Thus, while the oral product is dosed at the highest possible level,once pirfenidone enters the blood it is rapidly metabolized to anon-active species further reducing the drugs potential to achievesufficient lung levels required for substantial efficacy. In someembodiments, because oral inhalation and intranasal inhalation deliveryof pirfenidone or pyridone analogs can achieve effective lung tissuelevels directly, extra-lung metabolism is minimized.

In some embodiments, administration of pirfenidone or pyridone analogcompound by inhalation has reduced gastroinstestinal side-effects whencompared to oral administration. In some embodiments, the reducedgastroinstestinal side-effects with administration by inhalation avoidsthe need for initial dose-escalation. In some embodiments,administration of pirfenidone or pyridone analog by inhalation avoids orsubstantially avoids the gastrointestinal tract and therefore effectsobserved with oral administration of pirfenidone or pyridone analogcompound will be minimized or not present. In some embodiments, the lackof food effects with administration by inhalation will allow for fulldose delivery.

In some embodiments, pharmaceutical compositions described herein areused in the treatment of lung disease in mammal. In some embodiments,the pharmaceutical compositions described herein are administered to amammal by oral inhalation or intranasal inhalation methods for thepurpose of treating lung disease in the mammal. In some embodiments,lung disease includes, but is not limited to, asthma, chronicobstructive pulmonary disease (COPD), pulmonary fibrosis, idiopathicpulmonary fibrosis, radiation induced fibrosis, silicosis, asbestosinduced pulmonary or pleural fibrosis, acute lung injury, acuterespiratory distress syndrome (ARDS), sarcoidosis, usual interstitialpneumonia (UIP), cystic fibrosis, Chronic lymphocytic leukemia(CLL)-associated fibrosis, Hamman-Rich syndrome, Caplan syndrome, coalworker's pneumoconiosis, cryptogenic fibrosing alveolitis, obliterativebronchiolitis, chronic bronchitis, emphysema, pneumonitis, Wegner'sgranulamatosis, lung scleroderma, silicosis, interstitial lung disease,asbestos induced pulmonary and/or pleural fibrosis. In some embodiments,lung disease is lung fibrosis (i.e. pulmonary fibrosis). In someembodiments, lung disease is idiopathic pulmonary fibrosis.

Pulmonary Fibrosis

In some embodiments, the compositions and methods described herein cantreat or slow down the progression of or prevent pulmonary fibrosis. Insome embodiments, pulmonary fibrosis includes interstitial pulmonaryfibrosis. This group of disorders is characterized by scarring of deeplung tissue, leading to shortness of breath and loss of functionalalveoli, thus limiting oxygen exchange. Etiologies include inhalation ofinorganic and organic dusts, gases, fumes and vapors, use ofmedications, exposure to radiation, and development of disorders such ashypersensitivity pneumonitis, coal worker's pneumoconiosis, radiation,chemotherapy, transplant rejection, silicosis, byssinosis and geneticfactors

IPF as described herein refers to “idiopathic pulmonary fibrosis” and isin some embodiments a chronic disease that manifests over several yearsand is characterized by scar tissue within the lungs, in the absence ofknown provocation. Exercise-induced breathlessness and chronic dry coughmay be the prominent symptoms. IPF belongs to a family of lung disordersknown as the interstitial lung diseases (ILD) or, more accurately, thediffuse parenchymal lung diseases. Within this broad category of diffuselung diseases, IPF belongs to the subgroup known as idiopathicinterstitial pneumonia (IIP). There are seven distinct IIPs,differentiated by specific clinical features and pathological patterns.IPF is the most common form of IIP. It is associated with the pathologicpattern known as usual interstitial pneumonia (UIP); for that reason,IPF is often referred to as IPF/UIP. IPF is usually fatal, with anaverage survival of approximately three years from the time ofdiagnosis. There is no single test for diagnosing pulmonary fibrosis;several different tests including chest x-ray, pulmonary function test,exercise testing, bronchoscopy and lung biopsy are used in conjunctionwith the methods described herein.

Idiopathic pulmonary fibrosis (also known as cryptogenic fibrosingalveolitis) is the most common form of interstitial lung disease, andmay be characterized by chronic progressive pulmonary parenchymalfibrosis. It is a progressive clinical syndrome with unknown etiology;the outcome is frequently fatal as no effective therapy exists. In someembodiments, pirfenidone inhibits fibroblast proliferation anddifferentiation related to collagen synthesis, inhibits the productionand activity of TGF-beta, reduces production of fibronectin andconnective tissue growth factor, inhibits TNF-alpha and I-CAM, increaseproduction of IL-10, and/or reduces levels of platelet-derived growthfactor (PDGF) A and B in bleomycin-induced lung fibrosis. Thepirfenidone methods and compositions described herein may providetolerability and usefulness in patients with advanced idiopathicpulmonary fibrosis and other lung diseases. In some embodiments,pirfenidone methods and compositions described herein may providetolerability and usefulness in patients with mild to moderate idiopathicpulmonary fibrosis. In some embodiments, increased patient survival,enhanced vital capacity, reduced episodes of acute exacerbation(compared to placebo), and/or slowed disease progression are observedfollowing pirfenidone treatment. In some embodiments inhaled delivery ofpirfenidone or pyridone analog may be an effective means to prevent,manage or treat idiopathic pulmonary fibrosis or other pulmonaryfibrotic diseases.

The term “pulmonary fibrosis”, includes all interstitial lung diseaseassociated with fibrosis. In some embodiments, pulmonary fibrosisincludes the term “idiopathic pulmonary fibrosis” or “IPF”. In someembodiments, pulmonary fibrosis, by non-limiting example, may resultfrom inhalation of inorganic and organic dusts, gases, fumes and vapors,use of medications, exposure to radiation or radiation therapy, anddevelopment of disorders such as hypersensitivity pneumonitis, coalworker's pneumoconiosis, chemotherapy, transplant rejection, silicosis,byssinosis and genetic factors.

Exemplary lung diseases for the treatment or prevention using themethods described herein include, but are not limited, idiopathicpulmonary fibrosis, pulmonary fibrosis secondary to systemicinflammatory disease such as rheumatoid arthritis, scleroderma, lupus,cryptogenic fibrosing alveolitis, radiation induced fibrosis, chronicobstructive pulmonary disease (COPD), sarcoidosis, scleroderma, chronicasthma, silicosis, asbestos induced pulmonary or pleural fibrosis, acutelung injury and acute respiratory distress (including bacterialpneumonia induced, trauma induced, viral pneumonia induced, ventilatorinduced, non-pulmonary sepsis induced, and aspiration induced).

Inflammasome and Fibrosis

The innate immune response comprising the inflammasomes is one of thefirst lines of defense against tissue damage and pathogen invasion. Theinflammasome mediates the activation and recruitment of inflammatorycells to the site of danger through the release of proinflammatoryfactors. The inflammasomes are capable of recognizing endogenous andexogenous alarm signals arising from intracellular or extracellularstressors. Endogenous stressors that are known to activate theinflammasome include specific chemical alarm signals, such as uric acid,ATP, potassium efflux from the cell and the newly identified endogenouspeptide, acALY18. Exogenous stressors include pathogen-associatedmolecular patterns derived from a diverse range of conserved molecularmotifs that are unique to bacteria, viruses and parasites, fromexogenous chemicals or ultraviolet light. During inflammasome activationapoptosis speck-like protein containing a caspase activation andrecruitment domain (CARD) (ASC) moves from the nucleus and assemblesinto the inflammasome complex recruiting procaspase-1. The resultingassociation of these proteins causes the cleavage and activation ofcaspase-1. Once caspase-1 is activated, it is then able to cleave anumber of key pro-inflammatory cytokines, such as IL-113 and IL-18.

The NLRP3 inflammasome is the most extensively studied inflammasome andthis inflammasome is capable of sensing a wide variety of alarm signalsfrom endogenous and exogenous sources. It has been shown that theassembly of the NLRP3 inflammasome requires the presence of reactiveoxygen species and the positional interaction between the endoplasmicreticulum and mitochondria. Quiescent NLRP3 is localized to theendoplasmic reticulum. However, once the inflammasome is activated bothNLRP3 and ASC redistribute to the perinuclear region of the cell wherethey co-localize with the endoplasmic reticulum and mitochondrialorganelles.

Assembly and activation of the inflammasome complex leads to thecleavage of caspase-1 (IL-1β converting enzyme/ICE) in a process that istightly regulated. The active form of caspase-1 is able to cleave a widevariety of protein precursors that do not contain a secretion signalingsequence in a manner that appears to occur through an endoplasmicreticulum/Golgi-independent pathway that is now thought to involveautophagy. In addition to autophagy regulating the secretion of IL-1β,it also appears that autophagy may regulate the activation of theinflammasome. It has been shown that ASC is secreted from activatedmyofibroblasts at a higher rate than quiescent fibroblasts and othercells, suggesting that the inflammasome is secreted in a process thatregulates its own activation. Furthermore, once activated, caspase-1also induces its own secretion, possibly by the same autophagicmechanism, and we believe that this may also further regulate thecleavage of proteins that are processed by caspase-1.

IL-1β and IL-18 belong to the IL-1 family of proteins are processed intomature biologically active proteins when caspase-1 is activated. Theseproteins then become available for secretion. Numerous other proteinsare also processed by caspase-1 and many of these proteins are involvedin inflammation, the cytoskeleton of the cell and other functions.

Depending on the initiating mechanism, activation of the inflammasomecan run a well-defined course, with resolution of inflammation andhealing of the injury, or be continuous, resulting in chronic disease orfibrosis. It is speculated that in acute disease, the injury is able tobe completely resolved, with clearance of the initiating signal, whereasin chronic disease leading to fibrosis the resulting pathogen orirritant is unable to be cleared, leading to continuous inflammasomeactivation and IL-1β and IL-18 processing.

The role of IL-1β in fibrosis and wound healing is apparent and studieshave elucidated some of the downstream mechanisms that result in theinduction of collagen. IL-1β can directly stimulate collagen secretionby fibroblasts in a dose-dependent manner and the transientover-expression of IL-1β by airway epithelial cells increases TGFβ1 andcollagen deposition in the lung.

The transient expression of IL-1β is important for normal wound healing.However, chronic expression of IL-1β appears to mediate fibrosis. Innormal wound healing, IL-1β secretion is found to peak at day 1 anddeclines during days 3-7 post-injury. Employing a deep incisionalwound-healing model, mice deficient in the IL-1 receptor had improvedwound healing, with less fibrosis and more collagenolytic activity. Thewound fluids contained less TGFβ1, IL-6 and vascular endothelial growthfactor, and wild-type wounds following Anakinra (IL-1 receptorantagonist) treatment contained less fibrosis, suggesting that IL-1signaling is profibrotic.

Short-term IL-1β and TGFβ1 exposure (minutes) in proximal tubular cellsinhibited the phosphorylation of Smad3, and this in turn inhibiteddownstream TGFβ1 signaling. In contrast, long exposure (24 h) ofproximal tubular cells to IL-1β and TGFβ1 increased Smad3phosphorylation, further enhancing TGFβ1 signaling. Other cells alsoexhibit similar responses to IL-1β, and exposure of microvascularendothelial cells to IL-1β was found to promote the permanenttransformation of these cells into myofibroblasts.

IL-18 mRNA is constitutively expressed with low endogenous levels ofprotein in normal skin. Upon injury, the mRNA is rapidly translated intoprotein. Like IL-1β, IL-18 protein in wounded skin is transient andpeaks at days 5-7. Immediately after wounding, there is a rapid decreasein IL-18 mRNA in the skin, but this returns to normal levels by day 13,once re-epithelialization is complete. In wound healing, IL-18 inducesTGFβ1 and can induce IFNγ secretion by inflammatory cells.Interestingly, the inhibition of IFNγ signaling results in improvedwound healing compared to wild-type mice, suggesting that IFNγ isrequired for balanced wound healing and that its absence may promotefibrosis.

The involvement of the inflammasome in fibrotic diseases is beingelucidated. However, many studies to date have focused on inflammasomeactivation in inflammatory cells, rather than the activation of theinflammasome in stromal cells or parenchymal cells. Activation of theinflammasome appears to be involved in many chronic idiopathic diseasesin addition to being involved in pathogen recognition or the recognitionof cellular alarm signals (alarmins). It is speculated that fibrosiscould be dependent on a number of factors, including the initiatingevents leading to inflammasome activation, the specifically activatedinflammasome or inflammasome combination, the genetic variations thataffect the response of the target cell to the activated inflammasome,inflammasome by-products, such as IL-1β and IL-18, the level of cytokinesecreted from the cell, the cell type in which the inflammasome isactivated (inflammatory cells versus stromal or parenchymal cells) orthe duration of the activation of the inflammasome.

Even though stromal cells are not immune cells, activation of thesecells is capable of inducing cytokine secretion that promotes downstreamrecruitment of inflammatory cells, and this can occur by inflammasomeactivation. Fibroblasts have not been considered central to the immuneresponse, neither have they been considered to be immunologicallyrelevant in infections. However, they can become activated to release ofchemokines and cytokines for the recruitment of monocytes andneutrophils to sites when the skin has been breached or infected by apathogen. Fibroblasts may be considered a sentinel cell that respond tobacterial products and cellular alarm signals due to tissue damage.Inflammasome activation induces the differentiation of quiescentfibroblasts to myofibroblasts. From this, continuous inflammasomedysregulation that promotes myofibroblast differentiation may be a keyfactor in excessive extracellular matrix accumulation and resultingorgan failure. In contrast, in normal wound healing, inflammasomesignalling is tightly regulated and, once the wound is closed, themyofibroblasts undergo apoptosis, limiting collagen secretion.

Many studies corroborate the role of the NLRP3 inflammasome in drivingcollagen deposition in the tissues and the activation of caspase-1 inwound healing: 1. In mice deficient in ASC protein had attenuatedresponses to the profibrotic compound, bleomycin; 2. In mice deficientin the IL-1 receptor there were also abrogated responses to bleomycin;3. Direct administration of recombinant IL-1β into the lungs ofwild-type mice, resulted in marked increase in tissue destruction withinflammation and collagen deposition; and 4. Inhibition of IL-1signaling with the IL-1 receptor antagonist (Anakinra) limited fibrosisand was more effective than the administration of IL-1β-neutralizingantibodies.

In further studies it was found that uric acid was released into thelung parenchyma when bleomycin was instilled into the lungs. Uric acidis soluble in the cytosol of the cell. However, when it is released byinjured cells it precipitates, forming monosodium urate crystals thatare microscopic in size, and these crystals stimulate an immuneresponse. It was speculated that the localized increase in uric acidresulted in the deposition of crystals that cause membrane damage tocells, resulting in the activation of NLRP3 inflammasome and subsequentrelease of IL-1β. It was further demonstrated that the signalingmediated by uric acid was dependent on the IL-1 receptor and the NLRP3inflammasome, and suggested that an autocrine signaling loop mediatingresulting fibrosis. Utilizing the caspase-1 deficient mouse, it wasdemonstrated that caspase-1 was necessary for the profibrotic effect ofbleomycin.

Hepatic stellate cells are able to differentiate into myofibroblasts andup-regulate collagen secretion. Activated hepatic stellate cells canphagocytose pathogen and cellular debris, present antigen, expressα-smooth muscle actin stress fibers, and migrate. It has been shown thatmonosodium urate crystals activated the inflammasome, leading to liverfibrosis. Together, these findings further suggested that theinflammasome is an important signaling pathway central to fibroticdiseases. In addition, it was shown that progression liver fibrosis wasmediated by IL-1α and IL-1β, peaking on day 1, whereas collagen andα-smooth muscle actin peaked at day 3.

It has been shown that fibrosis in the autoimmune disease systemicsclerosis (SSc; scleroderma) is dependent on the inflammasome. It wasshown that collagen secretion by myofibroblasts could be abrogated ifcaspase-1 was inhibited and, by inhibiting caspase-1, IL-1β and IL-18were also inhibited. These data suggest that the release of IL-1β andIL-18 in SSc is mediated by an inflammasome activation that is dependenton caspase-1, and that this process is driving fibrosis. Furthermore,the pathogenic cell that drives the increased collagen synthesis in theskin and organs, the myofibroblast, could be phenotypically altered byinhibiting caspase-1. Specifically, α-smooth muscle actin stress fiberswere thinner and contained less protein when caspase-1 signaling wasinhibited. No change in α-smooth muscle actin expression was observed inquiescent fibroblasts and f-actin expression was unaffected by caspase-1inactivation. These findings were further recapitulated in NLRP3- andASC-deficient mice in a model of dermal fibrosis. The induction ofdermal fibrosis with subcutaneous injections of bleomycin was inhibitedin the knockout mice, as was pulmonary fibrosis. These findings suggestthat active caspase-1 regulates SSc fibrosis and suggests that there maybe autocrine signaling mediated by IL-1β and/or IL-18 that promotes theprofibrotic phenotype in these patients.

Recently it was found that stimulation of cardiac fibroblasts, but notcardiomyocytes, with conditions mimicking hypoxia and reoxygenationstimulated the inflammasome and that this could lead to fibrosis. Underthese conditions, reactive oxygen species and potassium efflux were thedriving forces behind inflammasome activation. ASC-deficient mice hadattenuated responses to ischaemia-reperfusion and reduced numbers ofinfiltrating macrophages and neutrophils. This study provides furtherevidence that fibroblasts may act as sentinel cells capable of sensingdanger signals that are a result of ischaemia and reperfusion, causingan enhanced inflammatory response in the heart and inciting thedeposition of collagens.

Endoplasmic Reticulum Stress and Fibrosis

The endoplasmic reticulum (ER) is a specialized cellular organelle thatfunctions as the site for folding of proteins destined for severalcellular compartments or the extracellular milieu. The ER also serves asa site for the biosynthesis for steroids, cholesterol and other lipids,and for the storage and cytosolic release of calcium. In addition, theER can activate several signaling pathways collectively called theunfolded protein response (UPR) when it sustains stress that challengesits function. In eukaryotic cells, three ER-resident transmembraneproteins are crucial for sensing ER stress and transducing signalsduring the UPR: inositol-requiring enzyme 1 (IRE1), double-strandedRNA-activated protein kinase-(PKR)-like eukaryotic initiation factor 2αkinase (PERK) and the activating transcription factor-6 (ATF6). Duringtransient and mild ER stress, the UPR restores ER homeostasis byadaptive mechanisms, including the expansion of ER size, enhancedprotein folding capacity, suppression of protein synthesis throughtranscriptional and translational controls, and degradation of unfoldedor misfolded proteins. However, if the stress is persistent and strong,the UPR activates mitochondria-dependent or mitochondria-independentapoptotic pathways. UPR signaling pathways are also involved in theactivation of NF-κB, the major transcription factor regulatinginflammatory processes. All three UPR pathways induced by the ER sensorsIRE1α and PERK, and ATF6 potentially contribute to NF-κB activationduring ER stress. During UPR activation the ER-resident IRE1α activatesNF-κB through the IκB kinase (IKK) complex recruited by the formation ofa complex between IRE1α and TRAF2. The kinase activity of IRE1αphosphorylates IKK, leading to degradation of I-κB and subsequentactivation of NF-κB. PERK-induced phosphorylation of a subunit of theeukaryotic initiation factor 2-alpha (eIF2α) decreases the level of IκBprotein by repression of I-κB translation, facilitating the nucleartranslocation of NF-κB to regulate the transcription of target genes. Inaddition to these mechanisms, NF-κB may be activated by calcium-mediatedROS production during ER stress. Taken together, NF-κB activationassociated with ER stress participates in the priming step of IL-1βproduction and inflammasome activation.

Kidney Fibrosis

In some embodiments, the compositions and methods described herein cantreat or slow down the progression of or prevent kidney fibrosis. Kidneyfibrosis may develop as a result of chronic infection, obstruction ofthe ureter by calculi, malignant hypertension, radiation therapy,transplant rejection, severe diabetic conditions, or chronic exposure toheavy metals. In addition, idiopathic glomerulosclerosis and renalinterstitial fibrosis have been reported in children and adults. Kidneyfibrosis correlates well with the overall loss of renal function.Studies have shown that oral pirfenidone provides protective effectagainst heavy metal challenge and fibrosis reversal following diabeticchallenge in rats. Additionally, the antifibrotic action of pirfenidonein renal fibrosis following partial nephrectomy in rats has also beenshown. Moreover, clinical studies administering oral pirfenidone haveshown slowed renal function decline in focal segmentalglomeruloschlerosis patients. In some embodiments, because the kidneysvasculature is immediately downstream of the lung, inhaled delivery ofpirfenidone or pyridone analog may be an effective means to prevent,manage or treat kidney fibrosis resulting from various medicalconditions or procedures without exposing the systemic compartment tootherwise toxic drug levels associated with oral administration.

The term “kidney fibrosis” by non-limiting example relates to remodelingassociated with or resulting chronic infection, obstruction of theureter by calculi, malignant hypertension, radiation therapy, transplantrejection, severe diabetic conditions or chronic exposure to heavymetals. In some embodiments, kidney fibrosis correlates well with theoverall loss of renal function.

Heart and Kidney Toxicity

In some embodiments, the compositions and methods described herein cantreat or slow down the progression of or prevent heart and/or kidneytoxicity. Chemotherapeutic agents have toxic effects upon multiple organduring therapy. By non-limiting example doxorubicin has a broad spectrumof therapeutic activity against various tumors. However, its clinicaluse is limited by its undesirable systemic toxicity, especially in theheart and kidney. Treatment with pirfenidone reduced the severity ofdoxorubicin-induced toxicity as assessed by reduced mortality,diminished volume of recovered fluid in the abdominal cavity, andseverity of cardiac and renal lesions at both the biochemical andmorphological levels. In some embodiments, because the heart and kidneyvasculature are immediately downstream of the lung, inhaled delivery ofpirfenidone or pyridone analog may be an effective means to prevent,manage or treat chemotherapy-induced cardiac and/or renal inflammationwithout exposing the systemic compartment to otherwise toxic drug levelsassociated with oral administration. In some embodiments, inhaleddelivery of pirfenidone or pyridone analog compound is used in thetreatment of heart toxicity and/or kidney toxicity associated withchemotherapy or other therapeutic agents in a human.

The term “heart toxicity” by non-limiting example may be associated withor caused by exposure to chemotherapeutic agents having toxic effects.By non-limiting example doxorubicin has a broad spectrum of therapeuticactivity against various tumors. However, its clinical use is limited byits undesirable systemic toxicity, especially in the heart and kidney.

The term “kidney toxicity” by non-limiting example may be associatedwith or caused by exposure to chemotherapeutic agents having toxiceffects. By non-limiting example doxorubicin has a broad spectrum oftherapeutic activity against various tumors. However, its clinical useis limited by its undesirable systemic toxicity, especially in the heartand kidney.

Cardiac Fibrosis

In some embodiments, the compositions and methods described herein cantreat or slow down the progression of or prevent cardiac fibrosis.Cardiac remodeling as in chronic hypertension involves myocytehypertrophy as well as fibrosis, an increased and non-uniform depositionof extracellular matrix proteins. The extracellular matrix connectsmyocytes, aligns contractile elements, prevents overextending anddisruption of myocytes, transmits force and provides tensile strength toprevent rupture. Fibrosis occurs in many models of hypertension leadingto an increased diastolic stiffness, a reduction in cardiac function andan increased risk of arrhythmias. If fibrosis rather than myocytehypertrophy is the critical factor in impaired cardiovascular function,then reversal of cardiac fibrosis by itself may return cardiac functiontowards normal. Since collagen deposition is a dynamic process,appropriate pharmacological intervention could selectively reverseexisting fibrosis and prevent further fibrosis and thereby improvefunction, even if the increased systolic blood pressure was unchanged.

Treatment of DOCA-salt hypertensive rats with pirfenidone reversed andprevented fibrosis. Suggesting that pirfenidone or pyridone analogtherapy may be an effective means to attenuate cardiac fibrosisassociated with chronic hypertension and also the functional impairmentof the heart in hypertensive humans. Moreover, the reversal of fibrosisfollowing pirfenidone treatment of streptozotocin-diabetic rats was alsoshown (Miric et al., 2001). Together, and because the heart vasculatureare immediately downstream of the lung, inhaled delivery of pirfenidoneor pyridone analog may be an effective means to prevent, manage or treatcardiac fibrosis resulting from various medical conditions orprocedures, including by non-limiting example viral or bacterialinfection, surgery, Duchenne muscular dystrophy, radiation,chemotherapy, and transplant rejection.

The term “cardiac fibrosis” by non-limiting example relates toremodeling associated with or resulting from viral or bacterialinfection, surgery, Duchenne muscular dystrophy, radiation therapy,chemotherapy, transplant rejection and chronic hypertension wheremyocyte hypertrophy as well as fibrosis is involved and an increased andnon-uniform deposition of extracellular matrix proteins occurs. Fibrosisoccurs in many models of hypertension leading to an increased diastolicstiffness, a reduction in cardiac function, an increased risk ofarrhythmias and impaired cardiovascular function.

Hepatic Fibrosis

In some embodiments, the compositions and methods described herein cantreat or slow down the progression of or prevent hepatic fibrosis.Hepatic fibrosis occurs consequence of severe liver damage in patientswith chronic liver disease, caused by non-limiting example persistentviral hepatitis, alcohol overload and autoimmune. Hepatic fibrosisinvolves an abnormal accumulation of extracellular matrix components,particularly collagens. Hepatic stellate cells are non-parenchymal livercells residing in the perisinusoidal space. These cells have been shownto be the major cellular source of extracellular matrix in hepaticfibrosis. Studies have shown that oral pirfenidone provides protectiveeffect against dimethylnitrosamine-induced hepatic fibrosis inpreventing weight loss, suppressed loss in liver weight, suppressedinduction of hepatic fibrosis determined by histological evaluation andreduced hepatic hydroxyproline levels. Expression of mRNA for type Icollagen and transforming growth factor-beta in the liver were alsosuppressed by pirfenidone treatment. Additionally, clinical studiesadministering oral pirfenidone have shown decreased fibrosis andimproved quality of life in Hepatitis C viral-related liver diseasepatients. Together, and because the liver vasculature is downstream ofthe lung, these results suggest that inhaled delivery of pirfenidone orpyridone analog may be an effective means to prevent, manage or treathepatic fibrosis resulting from various medical conditions or procedureswithout exposing the systemic compartment to otherwise toxic drug levelsassociated with oral administration.

The term “hepatic fibrosis” by non-limiting example may be associatedwith or caused by severe liver damage in patients with chronic liverdisease, caused by non-limiting example persistent viral hepatitis,alcohol overload and autoimmune diseases. Hepatic fibrosis involves anabnormal accumulation of extracellular matrix components, particularlycollagens. Hepatic stellate cells are non-parenchymal liver cellsresiding in the perisinusoidal space.

Multiple Sclerosis

In some embodiments, the compositions and methods described herein cantreat or slow down the progression of or prevent multiple sclerosis.Multiple sclerosis is a demyelinating disorder that is characterized byneurological deficits attributable to demyelinating lesions andprogressive axonal loss in the white matter. The evidence that TNF-alphaplays a pivotal role in the pathogenesis of multiple sclerosis led toevaluation of pirfenidone in this indication. In a clinical study, oralpirfenidone improved the Scripps Neurological Rating Scale scores overplacebo. Further, pirfenidone reduced the incidence of relapses and wasassociated with a marked improvement in bladder dysfunction. Together,and because the central nervous system vasculature is immediatelydownstream of the lung, these results suggest that inhaled delivery ofpirfenidone or pyridone analog may be an effective means to prevent,manage or treat multiple sclerosis without exposing the systemiccompartment to otherwise toxic drug levels associated with oraladministration.

The term “multiple sclerosis” is a demyelinating disorder that ischaracterized by neurological deficits attributable to demyelinatinglesions and progressive axonal loss in the white matter.

Chronic Obstructive Pulmonary Disease (COPD)

In some embodiments, the compositions and methods described herein cantreat or slow down the progression of or prevent COPD. Oxidants andoxidative stress due to, by non-limiting example, cigarette smokingpromote lung inflammation, which is mediated, at least in part, byactivation of the transcription factors nuclear factor (NF)-κB andactivator protein (AP)-1. These coordinate the expression of severalgenes thought to be important in COPD, such as interleukin (IL)-8 andTNFα. These pro-inflammatory cytokines and chemokines, together withIL-1β, strongly activate the p38 subgroup of mitogen-activated proteinkinases (MAPKs), a family of signal transduction enzymes that alsoinclude extracellular signal-regulated kinases (ERK) and c-junNH2-terminal kinases (JNK). JNK and p38 members are activated mainly bycytokines implicated in inflammation and apoptosis. Within the MAPKfamily, both the JNK and the p38 subgroups are involved in mediatingpro-inflammatory responses, though p38 seems to play a prominent role inCOPD. Pirfenidone has been shown to inhibit both TNF-alpha and p38-gammaMAPK. Moreover, silencing p38-gamma MAPK has been demonstrated to havepotential to restore COPD sensitivity to corticosteroids (Mercado etal., 2007). In some embodiments, inhaled delivery of pirfenidone orpyridone analog compound is used in the treatment of COPD in a human. Insome embodiments, inhaled delivery of pirfenidone or pyridone analog maybe an effective means to prevent, manage or treat COPD or associatedillness without exposing the systemic compartment to otherwise toxicdrug levels associated with oral administration. Moreover, inhaleddelivery of pirfenidone or pyridone analog may serve as conjunctivetherapy with corticosteroids to restore their usefulness in thisindication.

The term “chronic obstructive pulmonary disease” or “COPD” bynon-limiting example may be associated with or caused by exposure totobacco smoke and preexisting asthma. COPD describes a wide range ofairway disorders that range from simple chronic bronchitis (smokerscough) to the more severe chronic obstructive bronchitis. The additionof episodes of airway hyper-reactivity to the above syndrome establishesthe diagnosis of chronic asthmatic bronchitis. Chronic obstructivepulmonary disease includes, but is not limited to, chronic bronchitis,emphysema, and/or pulmonary hypertension.

Asthma

In some embodiments, the compositions and methods described herein cantreat or slow down the progression of or prevent asthma. TNF-alpha hasbeen shown to be a highly pro-inflammatory cytokine in asthma, as itupregulates adhesion molecules, increases mucin secretion, and promotesairway remodeling. TNF-alpha is produced by a large number of cells inthe airways, including mast cells, smooth muscle cells, epithelialcells, monocytes, and macrophages. This cytokine has been shown to berelevant and increased in patients with asthma. Clinical studies usinganti-TNF-alpha therapy have produced encouraging results. In one set ofstudies using a soluble form of recombinant human TNF-alpha receptor(etanercept) the medication improved FEV1 and improved quality of life.Another clinical study administering an anti-TNF-alpha antibody reducedasthma exacerbation (infliximab). However, because of concernsassociated with adverse events future investigation of these therapiesin asthma is unlikely. Because pirfenidone has been shown to inhibitTNF-alpha, inhaled delivery of pirfenidone or pyridone analog may be aneffective means to manage or treat asthma or associated illness withoutexposing the systemic compartment to otherwise toxic drug levelsassociated with oral administration. In some embodiments, inhaleddelivery of pirfenidone or pyridone analog compound is used in thetreatment of asthma in a human. Moreover, inhaled delivery ofpirfenidone or pyridone analog may serve as conjunctive therapy withcorticosteroids to restore their usefulness in asthma patientsexhibiting steroid resistance.

The term “asthma” is associated with or caused by environmental andgenetic factors. Asthma is a common chronic inflammatory disease of theairways characterized by variable and recurring symptoms, reversibleairflow obstruction, and bronchospasm. Symptoms include wheezing,coughing, chest tightness, and shortness of breath. The term asthma maybe used with one or more adjectives to indicate cause. Non-limitingexamples of asthma include, but are not limited to, allergic asthma,non-allergic asthma, acute severe asthma, chronic asthma, clinicalasthma, nocturnal asthma, allergen-induced asthma, aspirin-sensitiveasthma, exercise-induced asthma, child-onset asthma, adult-onset asthma,cough-variant asthma, occupational asthma, steroid-resistant asthma, orseasonal asthma.

Lung Inflammation

In some embodiments, the compositions and methods described herein cantreat or slow down the progression of or prevent lung inflammation.Pirfenidone therapy has shown to have anti-inflammatory effects inaddition to anti-fibrotic effects. In some embodiments, pirfenidone orpyridone analog compound is administered to a human to treat lunginflammation. Lung inflammation is associated with or contributes to thesymptoms of bronchitis, asthma, lung fibrosis, chronic obstructivepulmonary disorder (COPD), and pneumonitis.

Glaucoma Surgery Post-Operative Fibrosis

The success of glaucoma filtration surgery is dependent on the degree ofpost-operative wound healing and the amount of scar tissue formation.Bleb failure occurs as fibroblasts proliferate and migrate toward thewound, eventually causing scarring and closure of the fistula tract.This frequently leads to poor postoperative intraocular pressure controlwith subsequent progressive optic nerve damage. The use of adjunctiveantifibrotic agents such as 5-fluorouracil and mitomycin C hassignificantly improved the success rate of filtration surgery. However,because of their nonspecific mechanisms of action, these agents cancause widespread cell death and apoptosis, resulting in potentiallysight-threatening complications such as severe postoperative hypotony,bleb leaks, and endophthalmitis. Thus, alternative antifibrotic agentsare needed. For this purpose, the anti-fibrotic agent pirfenidone orpyridone analog may prove beneficial.

Cancer

Lung cancer mortality is high, and annual lung cancer deaths equalprostate, breast, colon, and rectum cancers combined. Despite theadvancement in knowledge on molecular mechanisms and the introduction ofmultiple new therapeutic lung cancer agents, the dismal 5-year survivalrate (11-15%) remains relatively unaltered. This reflects the limitedavailable knowledge on factors promoting oncogenic transformation to andproliferation of malignant cells.

Until recent years, the principal focus in cancer research has mostlybeen the malignant cell itself. As a consequence, today, there is asignificant discrepancy between the vast knowledge about cancer biologygenerated in experimental settings and the translation of this knowledgeinto information that can be used in clinical decision making.Understanding the nature of the tumor environment today may be equallyimportant for future cancer therapies as understanding cancer geneticsper se. Cancers are not simply autonomous neoplastic cells but alsocomposed of fibroblasts, immune cells, endothelial cells, andspecialized mesenchymal cells. These different cell types in the stromalenvironment can be recruited by malignant cells to support tumor growthand facilitate metastatic dissemination.

Although the “seed and soil” hypothesis was presented more than acentury ago, we are now starting to comprehend the complex crosstalkbetween the tumor cells (the “seeds”) and the tumor-growingmicroenvironment (the “soil”). We now know that tumor growth is notdetermined only by malignant cells, because interactions between cancercells and the stromal compartment have major impacts on cancer growthand progression. Aggressive malignant cells are clever at exploiting thetumor microenvironment: tumor cells can (1) reside in the stroma andtransform it, (2) alter the surrounding connective tissue, and (3)modify the metabolism of resident cells, thus yielding a stroma, whichis permissive rather than defensive.

Beyond overcoming the microenvironmental control by the host, keycharacteristics of cancer cells is their ability to invade the tissueand metastasize distantly. For invasion and metastasis, the concertedinteractions between fibroblasts, immune cells, and angiogenic cells andfactors are essential.

The tumor stroma basically consists of (1) the nonmalignant cells of thetumor such as CAFs, specialized mesenchymal cell types distinctive toeach tissue environment, innate and adaptive immune cells, andvasculature with endothelial cells and pericytes and (2) theextracellular matrix (ECM) consisting of structural proteins (collagenand elastin), specialized proteins (fibrilin, fibronectin, and elastin),and proteoglycans. Angiogenesis is central for cancer cell growth andsurvival and has hitherto been the most successful among stromal targetsin anticancer therapy. Initiation of angiogenesis requires matrixmetalloproteinase (MMP) induction leading to degradation of the basementmembrane, sprouting of endothelial cells, and regulation of pericyteattachment. However, CAFs play an important role in synchronizing theseevents through the expression of numerous ECM molecules and growthfactors, including transforming growth factor (TGF)-β, vascularendothelial growth factor (VEGF), and fibroblast growth factor (FGF2).

The normal tissue stroma is essential for maintenance and integrity ofepithelial tissues and contains a multitude of cells that collaborate tosustain normal tissue homeostasis. There is a continuous and bilateralmolecular crosstalk between normal epithelial cells and cells of thestromal compartment, mediated through direct cell-cell contacts or bysecreted molecules. Thus, minor changes in one compartment may causedramatic alterations in the whole system.

A similarity exists between stroma from wounds and tumors, because bothentities had active angiogenesis and numerous proliferating fibroblastssecreting a complex ECM, all on a background of fibrin deposition.Consequently, the tumor stroma has been commonly referred to asactivated or reactive stroma.

A genetic alteration during cancer development, leading to a malignantcell, will consequently change the stromal host compartment to establisha permissive and supportive environment for the cancer cell. Duringearly stages of tumor development and invasion, the basement membrane isdegraded, and the activated stroma, containing fibroblasts, inflammatoryinfiltrates, and newly formed capillaries, comes into direct contactwith the tumor cells. The basement membrane matrix also modifiescytokine interactions between cancer cells and fibroblasts. Thesecancer-induced alterations in the stroma will contribute to cancerinvasion. Animal studies have shown that both wounding and activatedstroma provides oncogenic signals to facilitate tumorigenesis. Althoughnormal stroma in most organs contains a minimal number of fibroblasts inassociation with physiologic ECM, the activated stroma is associatedwith more ECM-producing fibroblasts, enhanced vascularity, and increasedECM production. This formation of a specific tumor stroma type at sitesof active tumor cell invasion is considered an integral part of thetumor invasion and has been termed as tumor stromatogenesis.

The expansion of the tumor stroma with a proliferation of fibroblastsand dense deposition of ECM is termed a desmoplastic reaction. It issecondary to malignant growth and can be separated from alveolarcollapse, which do not show neither activated fibroblasts nor the densecollagen/ECM. Morphologically this is termed desmoplasia and wasinitially conceived as a defense mechanism to prevent tumor growth, butdata have shown that in established tumors, this process, quiteoppositely, participates in several aspects of tumor progression, suchas angiogenesis, migration, invasion, and metastasis. The latter studiesshow that fibroblasts and tumor cells can enhance local tissue growthand cancer progression through secreting ECM and degrading components ofECM within the tumor stroma. This is in part related to the release ofsubstances sequestered in the ECM, such as VEGF, and cleavage ofproducts from ECM proteins as a response to secretion ofcarcinoma-associated MMPs.

Profibrotic growth factors, released by cancer cells, such as TGF-β,platelet-derived growth factor (PDGF), and FGF2 govern the volume andcomposition of the tumor stroma as they are all key mediators offibroblast activation and tissue fibrosis. PDGF and FGF2 playsignificant roles in angiogenesis as well.

In tumors, activated fibroblasts are termed as peritumoral fibroblastsor carcinoma-associated fibroblasts (CAFs). CAFs, like activatedfibroblasts, are highly heterogeneous and believed to derive from thesame sources as activated fibroblasts. The main progenitor seems to bethe locally residing fibroblast, but they may also derive from pericytesand smooth muscle cells from the vasculature, from bone marrow-derivedmesenchymal cells, or by epithelial or endothelial mesenchymaltransition. The term CAF is rather ambiguous because of the variousorigins from which these cells are derived, as is the difference betweenactivated fibroblasts and CAFs. There are increasing evidence forepigenetic and possibly genetic distinctions between CAFs and normalfibroblasts. CAFs can be recognized by their expression of α-smoothmuscle actin, but due to heterogeneity α-smooth muscle actin expressionalone will not identify all CAFs. Hence, other used CAF markers arefibroblast-specific protein 1, fibroblast activation protein (FAP), andPDGF receptor (PDGFR) α/β.

In response to tumor growth, fibroblasts are activated mainly by TGF-β,chemokines such as monocyte chemotactic protein 1, and ECM-degradingagents such as MMPs. Although normal fibroblasts in several in vitrostudies have demonstrated an inhibitory effect on cancer progression,today, there is solid evidence for a cancer-promoting role of CAFs. Inbreast carcinomas, as much as 80% of stromal fibroblasts are consideredto have this activated phenotype (CAFs).

CAFs promote malignant growth, angiogenesis, invasion, and metastasis.The roles of CAFS and their potential as targets for cancer therapy havebeen studied in xenografts models, and evidence from translationalstudies has revealed a prognostic significance of CAFs in severalcarcinoma types.

In the setting of tumor growth, CAFs are activated and highly synthetic,secreting, for example, collagen type I and IV, extra domainA-fibronectin, heparin sulfate proteoglucans, secreted protein acidicand rich in cysteine, tenascin-C, connective tissue growth factors,MMPs, and plasminogen activators. In addition to secreting growthfactors and cytokines, which affect cell motility, CAFs are an importantsource for ECM-degrading proteases such as MMPs that play severalimportant roles in tumorigenesis. Through degradation of ECM, MMPs can,depending on substrate, promote tumor growth, invasion, angiogenesis,recruitment of inflammatory cells, and metastasis. Besides, a number ofproinflammatory cytokines seem to be activated by MMPs.

After injection of B16M melanoma cells in mice, the formation of livermetastases was associated with an early activation of stellate cells(fibroblast-like) in the liver, as these seemed important for creating ametastatic niche and promoting angiogenesis. MMPs have also been linkedto tumor angiogenesis in various in vivo models. CAFs, when coinjectedinto mice, facilitated the invasiveness of otherwise noninvasive cancercells. Furthermore, xenografts containing CAFs apparently grow fasterthan xenografts infused with normal fibroblasts.

At CAF recruitment and accumulation in the tumor stroma, these cellswill actively communicate with cancer cells, epithelial cells,endothelial cells, pericytes, and inflammatory cells through secretionof several growth factors, cytokines, and chemokines. CAFs providepotent oncogenic molecules such as TGF-β and hepatocyte growth factor(HGF).

TGF-β is a pleiotropic growth factor expressed by both cancer andstromal cells. TGF-β is, in the normal and premalignant cells, asuppressor of tumorigenesis, but as cancer cells progress, theantiproliferative effect is lost, and instead, TGF-β promotestumorigenesis by inducing differentiation into an invasive phenotype.TGF-β may also instigate cancer progression through escape fromimmunosurveillance, and increased expression of TGF-β correlate stronglywith the accumulation of fibrotic desmoplastic tissue and cancerprogression. Recently, a small molecule inhibitor of TGF-β receptor typeI was reported to inhibit the production of connective tissue growthfactor by hepatocellular carcinoma (HCC) cells, resulting in reducedstromal component of the HCCs. Inhibition of the TGF-β receptor abortedthe crosstalk between HCCs and CAFs and consequently avoided tumorproliferation, invasion, and metastasis. HGF belongs to the plasminogenfamily and is tethered to ECM in a precursor form. It binds to thehigh-affinity receptor c-met, and overexpression or constant oncogenicc-Met signaling lead to proliferation, invasion, and metastasis.

PDGFs are regulators of fibroblasts and pericytes and play importantroles in tumor progression. It is a chemotactic and growth factor formesenchymal and endothelial cells. It has a limited autocrine role intumor cell replication, but is a potential player, in a paracrinefashion, and in tumor stroma development. It induces the proliferationof activated fibroblasts and possibly recruits CAFs indirectly bystimulation of TGF-β release from macrophages.

A tumor cannot develop without the parallel expansion of a tumor stroma.Although we still do not comprehend the exact mechanisms regulatingfibroblast activation and their accumulation in cancer, the availableevidence points to the possibility that the tumor stroma or CAFs may becandidate targets for cancer treatment.

CAFs and MMPs have been considered two of the key regulators ofepithelial-derived tumors representing potential new targets forintegrative therapies, affecting both the transformed and nontransformedcomponents of the tumor environment. As commented earlier, theexperience with MMP inhibitors have so far been unsuccessful. Evidencethat CAFs are epigenetically and possibly also genetically distinct fromnormal fibroblasts is beginning to define these cells as potentialtargets for anticancer therapy. FAP, expressed in more than 90% ofepithelial carcinomas, emerged early as a promising candidate fortargeting CAFs, and the potential therapeutic benefit of its inhibitionwas reviewed recently. In preclinical studies, abrogation of FAPattenuates tumor growth and significantly enhance tumor tissue uptake ofanticancer drugs. In a phase I study, where patients with FAP-positiveadvanced carcinomas (colorectal cancer and NSCLC) were treated withFAP-antibody, the antibody bound specifically to tumor sites, but noobjective responses were observed.

The consistent and repeated findings of cancer cells that readilyundergo invasion and metastasis in response to TGF-β have pointed to theneed of novel anticancer agents targeting the oncogenic activities ofTGF-β. A large number of anti-TGF-β antibodies and TGF-β-receptor Ikinases have been tested preclinically during the past decade. Becauseof the lack of success, targeting of the TGF-β signaling system stillremains elusive. It should be noted that both protumoral and antitumoraleffects have been assigned to TGF-β, and the multifunctional nature ofTGF-β apparently represents the greatest barrier to effectively targetthis ligand, its receptor, or downstream effectors.

Pulmonary Hypertension

Pulmonary arterial hypertension (PAH) is a life-threatening diseasecharacterized by a marked and sustained elevation of pulmonary arterypressure. The disease results in right ventricular failure and death.Current therapeutic approaches for the treatment of chronic pulmonaryhypertension mainly provide symptomatic relief, as well as someimprovement of prognosis. Although postulated for all treatments,evidence for direct antiproliferative effects of most approaches ismissing. In addition, the use of most of the currently applied agents ishampered by either undesired side effects or inconvenient drugadministration routes. Pathological changes in hypertensive pulmonaryarteries include endothelial injury, proliferation, and hypercontractionof vascular smooth muscle cells (SMCs).

The World Health Organization divides pulmonary hypertension (PH) intofive groups. These groups are organized based on the cause of thecondition and treatment options. In all groups, the average pressure inthe pulmonary arteries is 25 mmHg or higher. The pressure in normalpulmonary arteries is 8-20 mmHg at rest. (Note that group 1 is calledpulmonary arterial hypertension (PAH) and groups 2 through 5 are calledpulmonary hypertension. However, together all groups are calledpulmonary hypertension.) Group 1 Pulmonary Arterial Hypertensionincludes PAH that has no known cause; PAH that's inherited; PAH that'scaused by drugs or toxins, such as street drugs and certain dietmedicines; PAH that's caused by conditions such as: Connective tissuediseases, HIV infection, Liver disease, Congenital heart disease. Thisis heart disease that's present at birth, Sickle cell disease,Schistosomiasis. This is an infection caused by a parasite.Schistosomiasis is one of the most common causes of PAH in many parts ofthe world; and PAH that is caused by conditions that affect the veinsand small blood vessels of the lungs. Group 2 Pulmonary Hypertensionincludes PH with left heart disease. Conditions that affect the leftside of the heart, such as mitral valve disease or long-term high bloodpressure, can cause left heart disease and PH. Left heart disease islikely the most common cause of PH. Group 3 Pulmonary Hypertensionincludes PH associated with lung diseases, such as COPD (chronicobstructive pulmonary disease) and interstitial lung diseases.Interstitial lung diseases cause scarring of the lung tissue. Group 3also includes PH associated with sleep-related breathing disorders, suchas sleep apnea. Group 4 Pulmonary Hypertension includes PH caused byblood clots in the lungs or blood clotting disorders. Group 5 PulmonaryHypertension includes PH caused by various other diseases or conditions.Examples include: Blood disorders, such as polycythemia vera andessential thrombocythemia, Systemic disorders, such as sarcoidosis andvasculitis. Systemic disorders involve many of the body's organs,Metabolic disorders, such as thyroid disease and glycogen storagedisease. (In glycogen storage disease, the body's cells don't use a formof glucose properly), and Other conditions, such as tumors that press onthe pulmonary arteries and kidney disease.

Several growth factors have been implicated in the abnormalproliferation and migration of SMCs, including PDGF, basic FGF (bFGF),and EGF. In vitro studies established that PDGF acts as a potent mitogenand chemoattractant for SMCs. Active PDGF is built up by polypeptides (Aand B chain) that form homo- or heterodimers and stimulate α and β cellsurface receptors. Recently, two additional PDGF genes were identified,encoding PDGF-C and PDGF-D polypeptides. The PDGF receptors (PDGFRs)belong to a family of transmembrane receptor tyrosine kinases (RTKs) andare supposed to be held together by the bivalent PDGF ligands. Thiscomplex of dimeric receptor and PDGF results in an autophosphorylationof the RTK and an increase in kinase activity.

Both receptors activate the major signaling transduction pathways,including Ras/MAPK, PI3K, and phospholipase Cy. Recently, upregulationof both PDGFRα and PDGFRβ has been shown in lambs with chronicintrauterine pulmonary hypertension. Pulmonary PDGF-A or PDGF-B mRNA,however, did not differ between pulmonary hypertensive and controlanimals. In lung biopsies from patients with severe pulmonary arterialhypertension (PAH), PDGF-A chain expression was significantly increased.

PDGF-A and PDGF-B mRNA synthesis and steady-state levels of PDGF-A andPDGF-B mRNAs and PDGF isoforms are elevated in bleomycin-treated lungs.Pirfenidone has been observed to suppress PDGF-A and PDGF-B levels,perhaps via a posttranscriptional or translational mechanism resultingin decreased PDGF-A and PDGF-B protein. Further, pirfenidone has beenobserved to reduce bleomycin-induced lung fibrosis by downregulating theexpression of PDGF-A as well as of PDGF-B proteins.

As altered PDGF signaling plays an important role in the course of PAH,pirfenidone or pyridone analog may also have a positive effect onhemodynamics and pulmonary vascular remodeling in PAH and serve as ananti-remodeling therapy for this disease.

The present invention provides, in several embodiments as hereindisclosed, compositions and methods for pirfenidone and pyridone analogcompound formulations that offer unprecedented advantages with respectto localized delivery of pirfenidone or pyridone analog in a manner thatpermits both rapid and sustained availability of therapeutically usefulpirfenidone or pyridone analog levels to one or more desired tissues.

In certain preferred embodiments, and as described in greater detailbelow, delivery of the pirfenidone or pyridone analog compoundformulation is to the respiratory tract tissues in mammalian subjects,for example, via the respiratory airways to middle airways and/orpulmonary beds (e.g., alveolar capillary beds) in human patients.According to certain particularly preferred embodiments, delivery tothese regions of the lung may be achieved by inhalation therapy of apirfenidone or pyridone analog compound formulation as described herein.

These and related embodiments will usefully provide therapeutic and/orprophylactic benefit, by making therapeutically effective pirfenidone orpyridone analog available to a desired tissue promptly uponadministration, while with the same administration event also offeringtime periods of surprisingly sustained duration during which locallydelivered pirfenidone or pyridone analog is available for a prolongedtherapeutic effect.

The compositions and methods disclosed herein provide for such rapid andsustained localized delivery of a pirfenidone or pirfenidone or pyridoneanalog pyridone analog compound to a wide variety of tissues.Contemplated are embodiments for the treatment of numerous clinicallysignificant conditions including pulmonary fibrosis, chronic obstructivepulmonary disease (COPD), asthma, cystic fibrosis, cardiac fibrosis,transplantation (e.g., lung, liver, kidney, heart, etc.), vasculargrafts, and/or other conditions such as multiple sclerosis for whichrapid and sustained bioavailable pirfenidone or pyridone analog therapymay be indicated.

Various embodiments thus provide compositions and methods for optimalprophylactic and therapeutic activity in prevention and treatment ofpulmonary fibrosis in human and/or veterinary subjects using aerosoladministration, and through the delivery of high-concentration (or dryformulation), sustained-release active drug exposure directly to theaffected tissue. Specifically, and in certain preferred embodiments,concentrated doses are delivered of a pirfenidone or pyridone analog.

Without wishing to be bound by theory, according to certain of these andrelated embodiments as described in greater detail herein, a pirfenidoneor pyridone analog is provided in a formulation having components thatare selected to deliver an efficacious dose of pirfenidone or pyridoneanalog following aerosolization of a liquid, dry powder or metered-doseformulation providing rapid and sustained localized delivery ofpirfenidone or pyridone analog to the site of desired effect.

According to certain related embodiments, regulation of the total amountof dissolved solutes in a pirfenidone or pyridone analog compoundformulation is believed, according to non-limiting theory, to result inaqueous pirfenidone or pyridone analog compound formulations havingtherapeutically beneficial properties, including the properties ofnebulized liquid particles formed from aqueous solutions of suchformulations. Additionally, and as disclosed herein, it has beendiscovered that within the parameters provided herein as pertain topirfenidone or pyridone analog compound concentration, pH, and totalsolute concentration, tolerability of formulations at or near the upperportion of the total solute concentration range can be increased byinclusion of a taste-masking agent as provided herein.

An unexpected observation is that exposure of inhaled pirfenidone to thelung surface results in depletion of essential lung-surface cations andincreased propensity for acute toxicity. The apparent mechanism for thisdepletion is pirfenidone's ability to chelate ions such as iron(III) ina ratio of three pirfenidone molecules per on iron(III) ion. Chelationof iron(III) occurs at about one-half the chelation strength of EDTA.One method to prevent lung-surface ion depletion is to formulationprifenidone with a multivalent ion. By non-limiting example, suchmulti-valent cations may include iron(II), iron(III), calcium,magnesium, etc. By non-limiting example, formulation of pirfenidone wasfound to chelate magnesium at a ratio of two pirfenidone molecules toone magnesium ion. Thus, formulation of between about two and tenpirfenidone molecules with one magnesium molecule results in filling orsaturating the chelation capacity of prifenidone and reducespirfenidone's to deplete lung-surface cations. Coupling this solutionwith the need to adjust formulation osmolality and permeant ion content,the salt form of multivalent ion may also be beneficial. By non-limitingexample, using magnesium chloride to formulate pirfenidone reducespirfenidone's ability to deplete essential lung-surface cations,contributes to adjusting the formulations osmolality and serves toprovide the formulation a chloride permeant ion. In certain suchembodiments, for example, a pirfenidone or pyridone analog compoundformulation that comprises pirfenidone or a pyridone analog alone orformulated with excipients dissolved in a simple aqueous solution thatmay be aerosolized and injected or inhaled to the nasal or pulmonarycompartment. Such a formulation may contain a multivalent cation and/orbe buffered to a pH from about 4.0 to about 11.0, more preferably fromabout pH 4.0 to about pH 8.0, at a concentration of at least 34 mcg/mLto about 463 mg/mL, and having a total osmolality at least 100 mOsmol/kgto about 6000 mOsmol/kg, or 300 to about 5000 mOsmol/kg. Such a simpleaqueous formulation may further comprise a taste-masking agent therebyto become tolerable for inhalation administration (i.e., to overcomeundesirable taste or irritative properties that would otherwise precludeeffective therapeutic administration). Hence and as described in greaterdetail herein, regulation of formulation conditions with respect to pH,buffer type, pirfenidone or pyridone analog concentration, totalosmolality and potential taste-masking agent, provides certaintherapeutic and other advantages.

In certain such embodiments, for example, a pirfenidone or pyridoneanalog compound formulation that comprises pirfenidone or a pyridoneanalog in a dry powder formulation alone or formulated with anexcipient, such as a multivalent cation providing improved stabilityand/or dispersion properties, such that at least 0.1 mg to about 100 mgmay be dispersed and injected or inhaled to the nasal or pulmonarycompartment. Hence and as described in greater detail herein, regulationof formulation conditions with respect to dispersion excipient,pirfenidone or pyridone analog stability (including, by non-limitingexample polymorph, amorphic content and water content), pirfenidone orpyridone analog amount and potential taste-masking agent, providescertain therapeutic and other advantages.

In certain such embodiments, for example, a pirfenidone or pyridoneanalog compound formulation that comprises pirfenidone or a pyridoneanalog in a pressurized meter-dose inhaler configuration providingimproved stability and/or aerosol properties, such that at least 0.1 mgto about 100 mg may be aerosolized and injected or inhaled to the nasalor pulmonary compartment. Hence and as described in greater detailherein, regulation of formulation conditions with respect to propellant,suitable pressurized metered-dose inhaler canister, pirfenidone orpyridone analog stability provides certain therapeutic and otheradvantages.

In certain preferred embodiments, a pirfenidone or pyridone analogcompound formulation or salts thereof may serve as prodrugs,sustained-release or active substances in the presently disclosedformulations and compositions and may be delivered, under conditions andfor a time sufficient to produce maximum concentrations ofsustained-release or active drug to the respiratory tract (includingpulmonary beds, nasal and sinus cavities), and other non-oral topicalcompartments including, but not limited to the skin, rectum, vagina,urethra, urinary bladder, eye, and ear. As disclosed herein, certainparticularly preferred embodiments relate to administration, via oraland/or nasal inhalation, of a pirfenidone or pyridone analog compound tothe lower respiratory tract, in other words, to the lungs or pulmonarycompartment (e.g., respiratory bronchioles, alveolar ducts, and/oralveoli), as may be effected by such “pulmonary delivery” to provideeffective amounts of the pirfenidone or pyridone analog compound to thepulmonary compartment and/or to other tissues and organs as may bereached via the circulatory system subsequent to such pulmonary deliveryof the pirfenidone or pyridone analog compound to the pulmonaryvasculature.

Because different drug products are known to have varying efficaciesdepending on the dose, form, concentration and delivery profile, certainpresently disclosed embodiments provide specific formulation anddelivery parameters that produce anti-inflammatory, anti-fibrotic,anti-demylination and/or tissue-remodeling results that are prophylacticor therapeutically significant. These and related embodiments thuspreferably include a pirfenidone or pyridone analog compound such aspirfenidone or pyridone analog alone or a salt thereof. As noted above,however, the invention is not intended to be so limited and may relate,according to particularly preferred embodiments, to pirfenidone or asalt thereof. Other contemplated embodiments may relate to anotherpyridone analog compound such as those disclosed herein.

As a non-limiting example, in a preferred embodiment, a pyridone analogcompound as provided herein (e.g., pirfenidone) formulated to permitmist, gas-liquid suspension or liquid nebulized, dry powder and/ormetered-dose inhaled aerosol administration to supply effectiveconcentrations or amounts conferring desired anti-inflammatory,anti-fibrotic or tissue-remodeling benefits, for instance, to prevent,manage or treat patients with pulmonary fibrosis.

Because different drug products are known to vary in efficacy dependingon the dose, form, concentration and delivery profile, the presentlydisclosed embodiments provide specific formulation and deliveryparameters that produce protection against and treatment for pulmonaryfibrosis associated, by non-limiting example with infection, radiationtherapy, chemotherapy, inhalation of environmental pollutants (e.g.dust, vapors, fumes, and inorganic and organic fibers),hypersensitivities, silicosis, byssinosis, genetic factors andtransplant rejection.

These and related applications are also contemplated for use in thediseased lung, sinus, nasal cavity, heart, kidney, liver, nervous systemand associated vasculature. The pirfenidone or pyridone analog compoundformulations and methods described herein may be used with commerciallyavailable inhalation devices, or with other devices for aerosoltherapeutic product administration.

As a non-limiting example, in a preferred embodiment, a pyridone analogcompound as provided herein (e.g., pirfenidone) formulated to permitmist, gas-liquid suspension or liquid nebulized, dry powder and/ormetered-dose inhaled aerosol administration to supply effectiveconcentrations or amounts conferring desired anti-inflammatory,anti-fibrotic or tissue-remodeling benefits, for instance, to prevent,manage or treat cardiac fibrosis in human and/or veterinary subjects.Such embodiments provide for direct and high concentration delivery ofthe pirfenidone or pyridone analog compound to the pulmonary vasculatureimmediately upstream of the left atrium and hence, to the coronaryarterial system with interlumenal atrial and ventricular exposure.

Because different drug products are known to vary in efficacy dependingon the dose, form, concentration and delivery profile, the presentlydisclosed embodiments provide specific formulation and deliveryparameters that produce protection against and treatment for cardiacfibrosis associated, by non-limiting example with infection, surgery,radiation therapy, chemotherapy and transplant rejection.

As a non-limiting example, in a preferred embodiment, a pyridone analogcompound as provided herein (e.g., pirfenidone) formulated to permitmist, gas-liquid suspension or liquid nebulized, dry powder and/ormetered-dose inhaled aerosol administration to supply effectiveconcentrations or amounts conferring desired anti-inflammatory,anti-fibrotic or tissue-remodeling benefits, for instance, to prevent,manage or treat kidney fibrosis. Such embodiments provide for direct andhigh concentration delivery of the pirfenidone or pyridone analogcompound to the pulmonary vasculature immediately upstream of the leftatrium, left ventrical and hence, to the kidney vasculature.

Because different drug products are known to vary in efficacy dependingon the dose, form, concentration and delivery profile, the presentlydisclosed embodiments provide specific formulation and deliveryparameters that produce protection against and treatment for kidneyfibrosis associated, by non-limiting example with infection, uretercalculi, malignant hypertension, radiation therapy, diabetes, exposureto heavy metals, chemotherapy and transplant rejection.

As a non-limiting example, in a preferred embodiment, a pyridone analogcompound as provided herein (e.g., pirfenidone) formulated to permitmist, gas-liquid suspension or liquid nebulized, dry powder and/ormetered-dose inhaled aerosol administration to supply effectiveconcentrations or amounts conferring desired anti-inflammatory benefits,for instance, to prevent, manage or treat heart or kidney toxicity. Suchembodiments provide for direct and high concentration delivery of thepirfenidone or pyridone analog compound to the pulmonary vasculatureimmediately upstream of the left atrium, left ventical, and hence, tothe heart and kidney vasculature.

Because different drug products are known to vary in efficacy dependingon the dose, form, concentration and delivery profile, the presentlydisclosed embodiments provide specific formulation and deliveryparameters that produce protection against and treatment for heart orkidney toxicity associated, by non-limiting example with chemotherapy.

As a non-limiting example, in a preferred embodiment, a pyridone analogcompound as provided herein (e.g., pirfenidone) formulated to permitmist, gas-liquid suspension or liquid nebulized, dry powder and/ormetered-dose inhaled aerosol administration to supply effectiveconcentrations or amounts conferring desired anti-inflammatory,anti-fibrotic or tissue-remodeling benefits, for instance, to prevent,manage or treat hepatic fibrosis. Such embodiments provide for directand high concentration delivery of the pirfenidone or pyridone analogcompound to the pulmonary vasculature immediately upstream of the leftatrium, left ventical and hence, to the hepatic vasculature.

Because different drug products are known to vary in efficacy dependingon the dose, form, concentration and delivery profile, the presentlydisclosed embodiments provide specific formulation and deliveryparameters that produce protection against and treatment for hepaticfibrosis associated, by non-limiting example with hepatic infection,hepatitis, alcohol overload, autoimmune disease, radiation therapy,chemotherapy and transplant rejection.

As a non-limiting example, in a preferred embodiment, a pyridone analogcompound as provided herein (e.g., pirfenidone) formulated to permitmist, gas-liquid suspension or liquid nebulized, dry powder and/ormetered-dose nasal-injected or inhaled, or orally-inhaled aerosoladministration to supply effective concentrations or amounts conferringdesired anti-inflammatory and/or anti-demylination benefits, forinstance, to prevent, manage or treat multiple sclerosis. If by oralinhalation, such embodiments provide for direct and high concentrationdelivery of the pirfenidone or pyridone analog compound to the pulmonaryvasculature immediately upstream of the left atrium, left ventical andhence, to the central nervous system. If by nasal injection or nasalinhalation, such embodiments provide for direct and high concentrationdelivery of the pirfenidone or pyridone analog compound to the nasal andsinus vasculature immediately upstream of the central nervous system.

Because different drug products are known to vary in efficacy dependingon the dose, form, concentration and delivery profile, the presentlydisclosed embodiments provide specific formulation and deliveryparameters that produce protection against and treatment for multiplesclerosis associated.

As a non-limiting example, in a preferred embodiment, a pyridone analogcompound as provided herein (e.g., pirfenidone) formulated to permitmist, gas-liquid suspension or liquid nebulized, dry powder and/ormetered-dose inhaled aerosol administration to supply effectiveconcentrations or amounts conferring desired anti-inflammatory,anti-fibrotic or tissue-remodeling benefits, for instance, to prevent,manage or treat patients with diseases associated with chronicobstructive pulmonary disease (COPD), including emphysema and chronicbronchitis.

Because different drug products are known to vary in efficacy dependingon the dose, form, concentration and delivery profile, the presentlydisclosed embodiments provide specific formulation and deliveryparameters that produce protection against and treatment for COPDassociated, by non-limiting example with exposure to pipe, cigar andcigarette smoke, secondhand smoke, air pollution, and chemical fumes ordust, and/or alpha-1 antitrypsin deficiency.

As a non-limiting example, in a preferred embodiment, a pyridone analogcompound as provided herein (e.g., pirfenidone) formulated to permitmist, gas-liquid suspension or liquid nebulized, dry powder and/ormetered-dose inhaled aerosol administration to supply effectiveconcentrations or amounts conferring desired anti-inflammatory benefits,for instance, to prevent, manage or treat patients with asthma.

Because different drug products are known to vary in efficacy dependingon the dose, form, concentration and delivery profile, the presentlydisclosed embodiments provide specific formulation and deliveryparameters that produce protection against and treatment for asthmaassociated, by non-limiting example with exercise, genetics, airborneallergens, inhaled irritants such as pipe, cigar and cigarette smoke,and childhood respiratory infection.

As a non-limiting example, in a preferred embodiment, a pyridone analogcompound as provided herein (e.g., pirfenidone) formulated to permitmist, gas-liquid suspension or liquid nebulized, dry powder and/ormetered-dose inhaled aerosol administration to supply effectiveconcentrations or amounts conferring desired anti-fibrotic,anti-inflammatory or tissue-remodeling benefits, for instance, toprevent, manage or treat patients with cystic fibrosis. Such embodimentsmay include co-formulation or co-administration of a pyridone analogcompound with an antibiotic, steroid, hyperosmolar solution, DNAse orother mucus thinning agent, or other agent.

Because different drug products are known to vary in efficacy dependingon the dose, form, concentration and delivery profile, the presentlydisclosed embodiments provide specific formulation and deliveryparameters that produce protection against and treatment for cysticfibrosis.

For the applications described herein, liquid nebulized, dry powder ormetered-dose aerosol pirfenidone or pyridone analog compound (or saltthereof) may be co-administered, administered sequentially or preparedin a fixed combination with an antimicrobial (e.g. tobramycin and/orother aminoglycoside such as amikacin, aztreonam and/or other beta ormono-bactam, ciprofloxacin, levofloxacin and/or other, fluoroquinolones,azithromycin and/or other macrolides or ketolides, tetracycline and/orother tetracyclines, quinupristin and/or other streptogramins, linezolidand/or other oxazolidinones, vancomycin and/or other glycopeptides, andchloramphenicol and/or other phenicols, and colisitin and/or otherpolymyxins), bronchodilator (e.g. beta-2 agonists and muscarinicantagonists), corticosteroids (e.g. salmeterol, fluticasone andbudesonide), glucocorticoids (e.g. prednisone), Cromolyn, Nedocromil,Leukotriene modifiers (e.g. montelukast, zafirlukast and zileuton)hyperosmolar solution, DNAse or other mucus thinning agent, interferongamma, cyclophosphamide, colchicine, N-acetylcysteine, azathioprine,bromhexine, endothelin receptor antagonist (e.g. bosentan andambrisentan), PDE5 inhibitor (e.g. sildenafil, vardenafil andtadalafil), PDE4 inhibitor (e.g. roflumilast, cilomilast, oglemilast,tetomilast and SB256066), prostinoid (e.g. epoprostenol, iloprost andtreprostinin), nitric oxide or nitric oxide-donating compound, IL-13blocker, IL-10 blocker, CTGF-specific antibody, CCN2 inhibitors,angiotensin-converting enzyme inhibitors, angiotensin receptorantagonists, PDGF inhibitors, PPAR antagonist, imatinib, CCL2-specificantibody, CXCR2 antagonist, triple growth factor kinase inhibitor,anticoagulant, TNF blocker, tetracycline or tetracycline derivative,5-lipoxygenase inhibitor, pituitary hormone inhibitor,TGF-beta-neutralizing antibody, copper chelator, angiotensin II receptorantagonist, chemokine inhibitor, NF-kappaB inhibitor, NF-kappaBantisense oligonucleotide, IKK-1 and -2 inhibitor (e.g.imidazoquinoxaline or derivative, and quinazoline or derivative), JNK2and/or p38 MAPK inhibitor (e.g. pyridylimidazolbutyn-I-ol, SB856553,SB681323, diaryl urea or derivative, and indole-5-carboxamide), PI3Kinhibitor, LTB4 inhibitor, antioxidant (e.g.Mn-pentaazatetracyclohexacosatriene, M40419, N-acetyl-L-cysteine,Mucomyst, Fluimucil, Nacystelyn, Erdosteine, Ebeselen, thioredoxin,glutathione peroxidase memetrics, Curcumin C3 complex, Resveratrol andanalogs, Tempol, catalytic antioxidants, and OxSODrol), TNF scavenger(e.g. infliximab, ethercept, adalumimab, PEG-sTNFR 1, afelimomab, andantisense TNF-alpha oligonucleotide), Interferon beta-1a (Avonex,Betaseron, or Rebif), glatiramer acetate (Copaxone), mitoxantrone(Novantrone), natalizumab (Tysabri), Methotrexate, azathioprine(Imuran), intravenous immunoglobulin (IVIg), cyclophosphamide (Cytoxan),lioresal (Baclofen), tizanidine (Zanaflex), benzodiazepine, cholinergicmedications, antidepressants and amantadine.

As shown as a promising approach to treat cancer and pulmonary arterialhypertension, to enable “cocktail therapy” or “cocktail prophylaxis” infibrotic disease, more specifically idiopathic pulmonary fibrosis andother pulmonary fibrotic disease, methods to administer pirfenidone orpyridone analog as either co-administered, administered sequentially, orco-prescribed (such that medicines are requested by a prescribingphysician to be taken in some sequence as combination therapy to treatthe same disease) with agents targeting cancer, fibrotic or inflammatorydisease are described. By non-limiting example, pirfenidone or pyridoneanalog is administered either in fixed combination, co-administered,adminstered sequentially, or co-prescribed with the monoclonal GS-6624(formerly known as AB0024), analog or another antibody targeting LOXL2protein associated with connective tissue biogenesis to reduceinflammation, tumor stroma and/or fibrosis. By another non-limitingexample, pirfenidone or pyridone analog is administered either in fixedcombination, co-administered, adminstered sequentially, or co-prescribedwith IW001 (Type V collagen), analog or other collagen targetingimmunogenic tolerance to reduce inflammation, tumor stroma and/orfibrosis. By another non-limiting example, pirfenidone or pyridoneanalog is administered either in fixed combination, co-administered,adminstered sequentially, or co-prescribed with PRM-151 (recombinantpentraxin-2), analog or other molecule targeting regulation of theinjury response to reduce inflammation, tumor stroma and/or fibrosis. Byanother non-limiting example, pirfenidone or pyridone analog isadministered either in fixed combination, co-administered, adminsteredsequentially, or co-prescribed with CC-930 (Jun kinase inhibitor),analog or other Jun kinase inhibitor to reduce the inflammatoryresponse. By another non-limiting example, pirfenidone or pyridoneanalog is administered either in fixed combination, co-administered,adminstered sequentially, or co-prescribed with imatinib (a.k.a. Gleeveor Glivec (tyrosin kinase inhibitor)), analog or other tyrosineinhibitor to inhibit lung fibroblast-myofibroblast transformation andproliferation as well as extracellular matrix production and tumorstroma formation/maintenance through inhibition of PDFG and transforminggrowth factor (TGF)-13 signaling. By another non-limiting example,pirfenidone or pyridone analog is administered either in fixedcombination, co-administered, adminstered sequentially, or co-prescribedwith STX-100 (monoclonal antibody targeting integrin alpha-v beta-6),analog or other antibody targeting integrin alpha-v beta-6 or otherintegrin to reduce tumor stroma and/or fibrosis. By another non-limitingexample, pirfenidone or pyridone analog is administered either in fixedcombination, co-administered, adminstered sequentially, or co-prescribedwith QAX576 (monoclonal antibody targeting interleukin 13 [IL-13]),analog or other antibody targeting IL-13 to reduce tumor stroma and/orinflammation. By another non-limiting example, pirfenidone or pyridoneanalog is administered either in fixed combination, co-administered,adminstered sequentially, or co-prescribed with FG-3019 (monoclonalantibody targeting connective tissue growth factor [CTGF]), analog orother antibody targeting CTGF to reduce tumor stroma and/or fibrosis. Byanother non-limiting example, pirfenidone or pyridone analog isadministered either in fixed combination, co-administered, adminsteredsequentially, or co-prescribed with CNTO-888 (a monoclonal antibodytargeting chemokine [C—C motif] ligand 2 [CCL2]), analog or otherantibody targeting CCL2 to reduce tumor stroma and/or fibrosis. Byanother non-limiting example, pirfenidone or pyridone analog isadministered either in fixed combination, co-administered, adminsteredsequentially, or co-prescribed with Esbriet, Pirespa or Pirfenex (tradenames for pirfenidone), or analog targeting inflammation, tumor stromaand/or fibrosis. By another non-limiting example, pirfenidone orpyridone analog is administered either in fixed combination,co-administered, adminstered sequentially, or co-prescribed withBIBF-1120 (also known as Vargatef; a triple kinase inhibitor targetingvascular endothelial growth factor [VEGF], platelet-derived growthfactor [PDGF] and fibroblast growth factor [FGF]), analog or othertriple kinase inhibitor to reduce fibrosis, tumor stroma and/orinflammation.

As with administration of pirfenidone, oral and parenteral routes ofadministration (by non-limiting example, intravenous and subcutaneous)of other compounds, molecules and antibodies targeting the reduction ofinflammation, tumor stroma and/or fibrosis is often associated with, bynon-limiting example, adverse reactions such as gastrointestinal sideeffects, liver, kidney, skin, cardiovascular or other toxicities. Asdescribed herein for pirfenidone or pyridone analogs, the benefits oforal or intranasal inhalation directly to the lung or tissuesimmediately downstream of the nasal and/or pulmonary compartments willalso benefit these compounds. Therefore, by non-limiting example, themonoclonal GS-6624 (formerly known as AB0024), analog or anotherantibody targeting LOXL2 protein associated with connective tissuebiogenesis to reduce inflammation, tumor stroma and/or fibrosis may beadministered by oral or intranasal inhalation for direct delivery to thelung or tissues immediately downstream of the nasal or pulmonarycompartments. By another non-limiting example, PRM-151 (recombinantpentraxin-2), analog or other molecule targeting regulation of theinjury response to reduce inflammation and/or fibrosis may beadministered by oral or intranasal inhalation for direct delivery to thelung or tissues immediately downstream of the nasal or pulmonarycompartments. By another non-limiting example, CC-930 (Jun kinaseinhibitor), analog or other Jun kinase inhibitor to reduce tumor stromaand/or the inflammatory response may be administered by oral orintranasal inhalation for direct delivery to the lung or tissuesimmediately downstream of the nasal or pulmonary compartments. Byanother non-limiting example, imatinib (a.k.a. Gleeve or Glivec (tyrosinkinase inhibitor)), analog or other tyrosine inhibitor to inhibit lungfibroblast-myofibroblast transformation and proliferation as well asextracellular matrix production and tumor stroma formation/maintenancethrough inhibition of PDFG and transforming growth factor (TGF)-βsignaling may be administered by oral or intranasal inhalation fordirect delivery to the lung or tissues immediately downstream of thenasal or pulmonary compartments. By another non-limiting example,STX-100 (monoclonal antibody targeting integrin alpha-v beta-6), analogor other antibody targeting integrin alpha-v beta-6 or other integrin toreduce tumor stroma and/or fibrosis may be administered by oral orintranasal inhalation for direct delivery to the lung or tissuesimmediately downstream of the nasal or pulmonary compartments. Byanother non-limiting example, QAX576 (monoclonal antibody targetinginterleukin 13 [IL-13]), analog or other antibody targeting IL-13 toreduce tumor stroma and/or inflammation may be administered by oral orintranasal inhalation for direct delivery to the lung or tissuesimmediately downstream of the nasal or pulmonary compartments. Byanother non-limiting example, FG-3019 (monoclonal antibody targetingconnective tissue growth factor [CTGF]), analog or other antibodytargeting CTGF to reduce tumor stroma and/or fibrosis may beadministered by oral or intranasal inhalation for direct delivery to thelung or tissues immediately downstream of the nasal or pulmonarycompartments. By another non-limiting example, CNTO-888 (a monoclonalantibody targeting chemokine [C—C motif] ligand 2 [CCL2]), analog orother antibody targeting CCL2 to reduce tumor stroma and/or fibrosis maybe administered by oral or intranasal inhalation for direct delivery tothe lung or tissues immediately downstream of the nasal or pulmonarycompartments. By another non-limiting example, BIBF-1120 (also known asVargatef; a triple kinase inhibitor targeting vascular endothelialgrowth factor [VEGF], platelet-derived growth factor [PDGF] andfibroblast growth factor [FGF]), analog or other triple kinase inhibitorto reduce tumor stroma and/or fibrosis and/or inflammation may beadministered by oral or intranasal inhalation for direct delivery to thelung or tissues immediately downstream of the nasal or pulmonarycompartments.

As shown as a promising approach to treat cancer and pulmonary arterialhypertension, to enable “cocktail therapy” or “cocktail prophylaxis” inpulmonary hypertension secondary to fibrotic disease, more specificallyType 3 Pulmonary Hypertension, methods to administer pirfenidone orpyridone analog as either co-administered, administered sequentially, orco-prescribed (such that medicines are requested by a prescribingphysician to be taken in some sequence as combination therapy to treatthe same disease) with agents targeting pulmonary hypertension, fibroticor inflammatory disease are described. By non-limiting example,pirfenidone or pyridone analog is administered either in fixedcombination, co-administered, adminstered sequentially, or co-prescribedwith the monoclonal GS-6624 (formerly known as AB0024), analog oranother antibody targeting LOXL2 protein associated with connectivetissue biogenesis to reduce inflammation, pulmonary hypertension and/orfibrosis. By another non-limiting example, pirfenidone or pyridoneanalog is administered either in fixed combination, co-administered,adminstered sequentially, or co-prescribed with IW001 (Type V collagen),analog or other collagen targeting immunogenic tolerance to reduceinflammation, pulmonary hypertension and/or fibrosis. By anothernon-limiting example, pirfenidone or pyridone analog is administeredeither in fixed combination, co-administered, adminstered sequentially,or co-prescribed with PRM-151 (recombinant pentraxin-2), analog or othermolecule targeting regulation of the injury response to reduceinflammation, pulmonary hypertension and/or fibrosis. By anothernon-limiting example, pirfenidone or pyridone analog is administeredeither in fixed combination, co-administered, adminstered sequentially,or co-prescribed with CC-930 (Jun kinase inhibitor), analog or other Junkinase inhibitor to reduce the inflammatory response. By anothernon-limiting example, pirfenidone or pyridone analog is administeredeither in fixed combination, co-administered, adminstered sequentially,or co-prescribed with imatinib (a.k.a. Gleeve or Glivec (tyrosin kinaseinhibitor)), analog or other tyrosine inhibitor to inhibit lungfibroblast-myofibroblast transformation and proliferation as well asextracellular matrix production and pulmonary hypertensionformation/maintenance through inhibition of PDFG and transforming growthfactor (TGF)-β signaling. By another non-limiting example, pirfenidoneor pyridone analog is administered either in fixed combination,co-administered, adminstered sequentially, or co-prescribed with STX-100(monoclonal antibody targeting integrin alpha-v beta-6), analog or otherantibody targeting integrin alpha-v beta-6 or other integrin to reducepulmonary hypertension and/or fibrosis. By another non-limiting example,pirfenidone or pyridone analog is administered either in fixedcombination, co-administered, adminstered sequentially, or co-prescribedwith QAX576 (monoclonal antibody targeting interleukin 13 [IL-13]),analog or other antibody targeting IL-13 to reduce pulmonaryhypertension and/or inflammation. By another non-limiting example,pirfenidone or pyridone analog is administered either in fixedcombination, co-administered, adminstered sequentially, or co-prescribedwith FG-3019 (monoclonal antibody targeting connective tissue growthfactor [CTGF]), analog or other antibody targeting CTGF to reducepulmonary hypertension and/or fibrosis. By another non-limiting example,pirfenidone or pyridone analog is administered either in fixedcombination, co-administered, adminstered sequentially, or co-prescribedwith CNTO-888 (a monoclonal antibody targeting chemokine [C—C motif]ligand 2 [CCL2]), analog or other antibody targeting CCL2 to reducepulmonary hypertension and/or fibrosis. By another non-limiting example,pirfenidone or pyridone analog is administered either in fixedcombination, co-administered, adminstered sequentially, or co-prescribedwith Esbriet, Pirespa or Pirfenex (trade names for pirfenidone), oranalog targeting inflammation, pulmonary hypertension and/or fibrosis.By another non-limiting example, pirfenidone or pyridone analog isadministered either in fixed combination, co-administered, adminsteredsequentially, or co-prescribed with BIBF-1120 (also known as Vargatef; atriple kinase inhibitor targeting vascular endothelial growth factor[VEGF], platelet-derived growth factor [PDGF] and fibroblast growthfactor [FGF]), analog or other triple kinase inhibitor to reducefibrosis, pulmonary hypertension and/or inflammation. By anothernon-limiting example, pirfenidone or pyridone analog is administeredeither in fixed combination, co-administered, adminstered sequentially,or co-prescribed with an endothelin receptor antagonist (e.g., bosentanor ambrisentan) to treat pulmonary hypertension in association withcancer, tumor stroma or fibrosis. By another non-limiting example,pirfenidone or pyridone analog is administered either in fixedcombination, co-administered, adminstered sequentially, or co-prescribedwith a PDE5 inhibitor (e.g. sildenafil, vardenafil and tadalafil) totreat pulmonary hypertension in association with cancer, tumor stroma orfibrosis. By another non-limiting example, pirfenidone or pyridoneanalog is administered either in fixed combination, co-administered,adminstered sequentially, or co-prescribed with a prostinoid (e.g.epoprostenol, iloprost and treprostinin) to treat pulmonary hypertensionin association with cancer, tumor stroma or fibrosis. By anothernon-limiting example, pirfenidone or pyridone analog is administeredeither in fixed combination, co-administered, adminstered sequentially,or co-prescribed with a nitric oxide or nitric oxide-donating compound(e.g., nitrate, nitrite or inhaled nitrite) to treat pulmonaryhypertension in association with cancer, tumor stroma or fibrosis.

As with administration of pirfenidone, oral and parenteral routes ofadministration (by non-limiting example, intravenous and subcutaneous)of other compounds, molecules and antibodies targeting the reduction ofinflammation, pulmonary hypertension and/or fibrosis is often associatedwith, by non-limiting example, adverse reactions such asgastrointestinal side effects, liver, kidney, skin, cardiovascular orother toxicities. As described herein for pirfenidone or pyridoneanalogs, the benefits of oral or intranasal inhalation directly to thelung or tissues immediately downstream of the nasal and/or pulmonarycompartments will also benefit these compounds. Therefore, bynon-limiting example, the monoclonal GS-6624 (formerly known as AB0024),analog or another antibody targeting LOXL2 protein associated withconnective tissue biogenesis to reduce inflammation, pulmonaryhypertension and/or fibrosis may be administered by oral or intranasalinhalation for direct delivery to the lung or tissues immediatelydownstream of the nasal or pulmonary compartments. By anothernon-limiting example, PRM-151 (recombinant pentraxin-2), analog or othermolecule targeting regulation of the injury response to reduceinflammation, pulmonary hypertension and/or fibrosis may be administeredby oral or intranasal inhalation for direct delivery to the lung ortissues immediately downstream of the nasal or pulmonary compartments.By another non-limiting example, CC-930 (Jun kinase inhibitor), analogor other Jun kinase inhibitor to reduce pulmonary hypertension and/orthe inflammatory response may be administered by oral or intranasalinhalation for direct delivery to the lung or tissues immediatelydownstream of the nasal or pulmonary compartments. By anothernon-limiting example, imatinib (a.k.a. Gleeve or Glivec (tyrosin kinaseinhibitor)), analog or other tyrosine inhibitor to inhibit lungfibroblast-myofibroblast transformation and proliferation as well asextracellular matrix production and pulmonary hypertension throughinhibition of PDFG and transforming growth factor (TGF)-β signaling maybe administered by oral or intranasal inhalation for direct delivery tothe lung or tissues immediately downstream of the nasal or pulmonarycompartments. By another non-limiting example, STX-100 (monoclonalantibody targeting integrin alpha-v beta-6), analog or other antibodytargeting integrin alpha-v beta-6 or other integrin to reduce pulmonaryhypertension and/or fibrosis may be administered by oral or intranasalinhalation for direct delivery to the lung or tissues immediatelydownstream of the nasal or pulmonary compartments. By anothernon-limiting example, QAX576 (monoclonal antibody targeting interleukin13 [IL-13]), analog or other antibody targeting IL-13 to reducepulmonary hypertension and/or inflammation may be administered by oralor intranasal inhalation for direct delivery to the lung or tissuesimmediately downstream of the nasal or pulmonary compartments. Byanother non-limiting example, FG-3019 (monoclonal antibody targetingconnective tissue growth factor [CTGF]), analog or other antibodytargeting CTGF to reduce pulmonary hypertension and/or fibrosis may beadministered by oral or intranasal inhalation for direct delivery to thelung or tissues immediately downstream of the nasal or pulmonarycompartments. By another non-limiting example, CNTO-888 (a monoclonalantibody targeting chemokine [C—C motif] ligand 2 [CCL2]), analog orother antibody targeting CCL2 to reduce pulmonary hypertension and/orfibrosis may be administered by oral or intranasal inhalation for directdelivery to the lung or tissues immediately downstream of the nasal orpulmonary compartments. By another non-limiting example, BIBF-1120 (alsoknown as Vargatef; a triple kinase inhibitor targeting vascularendothelial growth factor [VEGF], platelet-derived growth factor [PDGF]and fibroblast growth factor [FGF]), analog or other triple kinaseinhibitor to reduce pulmonary hypertension and/or fibrosis and/orinflammation may be administered by oral or intranasal inhalation fordirect delivery to the lung or tissues immediately downstream of thenasal or pulmonary compartments. By another non-limiting example, anendothelin receptor antagonist (e.g., bosentan or ambrisentan) to treatpulmonary hypertension in association with cancer, tumor stroma orfibrosis. By another non-limiting example, a PDE5 inhibitor (e.g.sildenafil, vardenafil and tadalafil) to treat pulmonary hypertension inassociation with cancer, tumor stroma or fibrosis. By anothernon-limiting example, a prostinoid (e.g. epoprostenol, iloprost andtreprostinin) to treat pulmonary hypertension in association withcancer, tumor stroma or fibrosis. By another non-limiting example, anitric oxide or nitric oxide-donating compound (e.g., nitrate, nitriteor inhaled nitrite) to treat pulmonary hypertension in association withcancer, tumor stroma or fibrosis.

As shown as a promising approach to treat cancer and pulmonary arterialhypertension, to enable “cocktail therapy” or “cocktail prophylaxis” incancer, more specifically lung cancer, methods to administer pirfenidoneor pyridone analog as either co-administered, administered sequentially,or co-prescribed (such that medicines are requested by a prescribingphysician to be taken in some sequence as combination therapy to treatthe same disease) with agents targeting cancer are described.Anti-cancer agents may include gefitinib (Iressa, also known as ZD1839).Gefitinib is a selective inhibitor of epidermal growth factor receptor's(EGFR) tyrosine kinase domain. The target protein (EGFR) is a family ofreceptors which includes Her1(erb-B1), Her2(erb-B2), and Her 3(erb-B3).EGFR is overexpressed in the cells of certain types of humancarcinomas—for example in lung and breast cancers. This leads toinappropriate activation of the anti-apoptotic Ras signalling cascade,eventually leading to uncontrolled cell proliferation. Research ongefitinib-sensitive non-small cell lung cancers has shown that amutation in the EGFR tyrosine kinase domain is responsible foractivating anti-apoptotic pathways. These mutations tend to conferincreased sensitivity to tyrosine kinase inhibitors such as gefitiniband erlotinib. Of the types of non-small cell lung cancer histologies,adenocarcinoma is the type that most often harbors these mutations.These mutations are more commonly seen in Asians, women, and non-smokers(who also tend to more often have adenocarcinoma). Gefitinib inhibitsEGFR tyrosine kinase by binding to the adenosine triphosphate(ATP)-binding site of the enzyme. Thus the function of the EGFR tyrosinekinase in activating the anti-apoptotic Ras signal transduction cascadeis inhibited, and malignant cells are inhibited. While gefitinib has yetto be proven to be effective in other cancers, there is potential forits use in the treatment of other cancers where EGFR overexpression isinvolved. As gefitinib is a selective chemotherapeutic agent, itstolerability profile is better than previous cytotoxic agents. Adversedrug reactions (ADRs) are acceptable for a potentially fatal disease.Acne-like rash is reported very commonly. Other common adverse effectsinclude: diarrhoea, nausea, vomiting, anorexia, stomatitis, dehydration,skin reactions, paronychia, asymptomatic elevations of liver enzymes,asthenia, conjunctivitis, blepharitis. Infrequent adverse effectsinclude: interstitial lung disease, corneal erosion, aberrant eyelashand hair growth.

Another anti-cancer agent is Erlotinib (also known as Tarceva).Erlotinib specifically targets the epidermal growth factor receptor(EGFR) tyrosine kinase, which is highly expressed and occasionallymutated in various forms of cancer. It binds in a reversible fashion tothe adenosine triphosphate (ATP) binding site of the receptor. For thesignal to be transmitted, two EGFR molecules need to come together toform a homodimer. These then use the molecule of ATP totrans-phosphorylate each other on tyrosine residues, which generatesphosphotyrosine residues, recruiting the phosphotyrosine-bindingproteins to EGFR to assemble protein complexes that transduce signalcascades to the nucleus or activate other cellular biochemicalprocesses. By inhibiting the ATP, formation of phosphotyrosine residuesin EGFR is not possible and the signal cascades are not initiated.Erlotinib has shown a survival benefit in the treatment of lung cancer.Erlotinib is approved for the treatment of locally advanced ormetastatic non-small cell lung cancer that has failed at least one priorchemotherapy regimen. It is also approved in combination withgemcitabine for treatment of locally advanced, unresectable, ormetastatic pancreatic cancer. In lung cancer, erlotinib has been shownto be effective in patients with or without EGFR mutations, but appearsto be more effective in the group of patients with EGFR mutations. Theresponse rate among EGFR mutation positive patients is approximately60%. Patients who are non-smokers, and light former smokers, withadenocarcinoma or subtypes like BAC are more likely to have EGFRmutations, but mutations can occur in all types of patients. EGFRpositive patients are generally KRAS negative. Erlotinib has recentlybeen shown to be a potent inhibitor of JAK2V617F activity. JAK2V617F isa mutant of tyrosine kinase JAK2, is found in most patients withpolycythemia vera (PV) and a substantial proportion of patients withidiopathic myelofibrosis or essential thrombocythemia. The studysuggests that erlotinib may be used for treatment of JAK2V617F-positivePV and other myeloproliferative disorder. Rash occurs in the majority ofpatients. This resembles acne and primarily involves the face and neck.It is self-limited and resolves in the majority of cases, even withcontinued use. Interestingly, some clinical studies have indicated acorrelation between the severity of the skin reactions and increasedsurvival though this has not been quantitatively assessed. Cutaneousrash may be a surrogate marker of clinical benefit. Other side effectsinclude diarrhea, loss of appetite, fatigue, rarely, interstitialpneumonitis, which is characterized by cough and increased dyspnea. Thismay be severe and must be considered among those patients whosebreathing acutely worsens. It has also been suggested that erlotinib cancause hearing loss. Rare side effects include serious gastrointestinaltract, skin, and ocular disorders. In addition, some people prescribederlotinib have developed serious or fatal gastrointestinal tractperforations; “bullous, blistering, and exfoliative skin conditions,some fatal; and serious eye problems such as corneal lesions. Some ofthe cases, including ones which resulted in death, were suggestive ofStevens-Johnson syndrome/toxic epidermal necrolysis. Erlotinib is mainlymetabolized by the liver enzyme CYP3A4. Compounds which induce thisenzyme (i.e. stimulate its production), such as St John's wort, canlower erlotinib concentrations, while inhibitors can increaseconcentrations. As with other ATP competitive small molecule tyrosinekinase inhibitors, such as imatinib in CML, patients rapidly developresistance. In the case of erlotinib this typically occurs 8-12 monthsfrom the start of treatment. Over 50% of resistance is caused by amutation in the ATP binding pocket of the EGFR kinase domain involvingsubstitution of a small polar threonine residue with a large nonpolarmethionine residue (T790M). While proponents of the ‘gatekeeper’mutation hypothesis suggest this mutation prevents the binding oferlotinib through steric hindrance, research suggests that T790M confersan increase in ATP binding affinity reducing the inhibitory effect oferlotinib. Approximately 20% of drug resistance is caused byamplification of the hepatocyte growth factor receptor, which drivesERBB3 dependent activation of PI3K. Other cases of resistance caninvolve numerous mutations, including recruitment of a mutated IGF-1receptor to homodimerize with EGFR so forming a heterodimer. This allowsactivation of the downstream effectors of EGFR even in the presence ofan EGFR inhibitor. Some IGR-1R inhibitors are in various stages ofdevelopment (based either around TKIs such as AG1024 or AG538 orpyrrolo[2,3-d]-pyrimidine derivatives such as NVP-AEW541). Themonoclonal antibody figitumumab which targets the IGF-1R is currentlyundergoing clinical trials. Another cause of resistance can beinactivating mutations of the PTEN tumor suppressor which allowincreased activation of Akt independent of stimulation by EGFR. The mostpromising approach to combating resistance is likely to be combinationtherapy. Commencing treatment with a number of different therapeuticagents with differing modes of action is thought to provide the bestdefense against development of T790M and other resistance conferringmutations.

Another anti-cancer agent is Bortezomib (originally codenamed PS-341;marketed as Velcade and Bortecad). Bortezomib is the first therapeuticproteasome inhibitor to be tested in humans. It is approved in the U.S.for treating relapsed multiple myeloma and mantle cell lymphoma. Inmultiple myeloma, complete clinical responses have been obtained inpatients with otherwise refractory or rapidly advancing disease.Bortezomib was originally synthesized as MG-341. After promisingpreclinical results, the drug (PS-341) was tested in a small Phase Iclinical trial on patients with multiple myeloma cancer. Bortezomib(Velcade) is approved for use in multiple myeloma. Another commerciallyavailable bortezomib product—Bortenat, reportedly contains substantiallymore active entity than declared, potentially and even more resulting inincreased toxicity. Moreover, Bortenat has some other chemical andformulation deviations from the registered ethic product Velcade, withunclear clinical impact. The boron atom in bortezomib binds thecatalytic site of the 26S proteasome with high affinity and specificity.In normal cells, the proteasome regulates protein expression andfunction by degradation of ubiquitylated proteins, and also cleanses thecell of abnormal or misfolded proteins. Clinical and preclinical datasupport a role in maintaining the immortal phenotype of myeloma cells,and cell-culture and xenograft data support a similar function in solidtumor cancers. While multiple mechanisms are likely to be involved,proteasome inhibition may prevent degradation of pro-apoptotic factors,permitting activation of programmed cell death in neoplastic cellsdependent upon suppression of pro-apoptotic pathways. Recently, it wasfound that bortezomib caused a rapid and dramatic change in the levelsof intracellular peptides that are produced by the proteasome. Someintracellular peptides have been shown to be biologically active, and sothe effect of bortezomib on the levels of intracellular peptides maycontribute to the biological and/or side effects of the drug. Bortezomibis rapidly cleared following intravenous administration. Peakconcentrations are reached at about 30 minutes. Drug levels can nolonger be measured after an hour. Pharmacodynamics are measured bymeasuring proteasome inhibition in peripheral blood mononuclear cells.The much greater sensitivity of myeloma cell lines and mantle cell linesto proteasome inhibition compared with normal peripheral bloodmononuclear cells and most other cancer cell lines is poorly understood.Bortezomib is associated with peripheral neuropathy in 30% of patients;occasionally, it can be painful. This can be worse in patients withpre-existing neuropathy. In addition, myelosuppression causingneutropenia and thrombocytopenia can also occur and be dose-limiting.However, these side effects are usually mild relative to bone marrowtransplantation and other treatment options for patients with advanceddisease. Bortezomib is associated with a high rate of shingles, althoughprophylactic acyclovir can reduce the risk of this. Gastro-intestinaleffects and asthenia are the most common adverse events. The establishedthe efficacy of bortezomib is 1.3 mg/m2 (with or without dexamethasone)administered by intravenous bolus on days 1, 4, 8, and 11 of a 21-daycycle for a maximum of eight cycles in heavily pretreated patients withrelapsed/refractory multiple myeloma. The demonstrated superiority ofbortezomib is 1.3 mg/m2 over a high-dose dexamethasone regimen (byexample median TTP 6.2 vs 3.5 months, and 1-year survival 80% vs. 66%).Laboratory studies and clinical trials are investigating whether itmight be possible to further increase the anticancer potency ofbortezomib by combining it with novel types of other pharmacologicagents. For example, clinical trials have indicated that the addition ofthalidomide, lenalidomide, inhibitors of vascular endothelial growthfactor (VEGF), or arsenic trioxide might be beneficial. In laboratorystudies, it was found that bortezomib killed multiple myeloma cells moreefficiently when combined, for example, with histone deacetylaseinhibitors, thapsigargin, or celecoxib. There is preclinical evidencethat bortezomib is synergistic with Reolysin in pancreatic cancer.However, the therapeutic efficacy and safety of any of these lattercombinations has not yet been evaluated in cancer patients.

Another family of anti-cancer agent are Janus kinase inhibitors. Alsoknown as JAK inhibitors, these are a type of medication that functionsby inhibiting the activity of one or more of the Janus kinase family ofenzymes (JAK1, JAK2, JAK3, TYK2), thereby interfering with the JAK-STATsignaling pathway. These inhibitors have therapeutic application in thetreatment of cancer and inflammatory diseases. Cytokines play key rolesin controlling cell growth and the immune response. Many cytokinesfunction by binding to and activating type I and type II cytokinereceptors. These receptors in turn rely on the Janus kinase (JAK) familyof enzymes for signal transduction. Hence drugs that inhibit theactivity of these Janus kinases block cytokine signaling. Morespecifically, Janus kinases phosphorylate activated cytokine receptors.These phosphorylated receptor in turn recruit STAT transcription factorswhich modulate gene transcription. The first JAK inhibitor to reachclinical trials was tofacitinib. Tofacitinib is a specific inhibitor ofJAK3 (IC50=2 nM) thereby blocking the activity of IL-2, IL-4, IL-15 andIL-21. Hence Th2 cell differentiation is blocked and thereforetofacitinib is effective in treating allergic diseases. Tofacitinib to alesser extent also inhibits JAK1 (IC50=100 nM) and JAK2 (IC50=20 nM)which in turn blocks IFN-γ and IL-6 signaling and consequently Th1 celldifferentiation. Examples of JAK inhibitors include: Ruxolitinib againstJAK1/JAK2 for psoriasis, myelofibrosis, and rheumatoid arthritis;Tofacitinib (tasocitinib; CP-690550) against JAK3 for psoriasis andrheumatoid arthritis; Baricitinib (LY3009104, INCB28050) againstJAK1/JAK2 for rheumatoid arthritis; CYT387 against JAK2 formyeloproliferative disorders; Lestaurtinib against JAK2, for acutemyelogenous leukemia (AML); Pacritinib (SB1518) against JAK2 forrelapsed lymphoma and advanced myeloid malignancies, chronic idiopathicmyelofibrosis (CIMF); and TG101348 against JAK2 for myelofibrosis.

Another family of anti-cancer agent is ALK inhibitors. ALK inhibitorsare potential anti-cancer drugs that act on tumors with variations ofanaplastic lymphoma kinase (ALK) such as an EML4-ALK translocation.About 7% of Non-small cell lung carcinomas (NSCLC) have EML4-ALKtranslocations. Examples of ALK inhibitors include: Crizotinib (tradename Xalkori) is approved for NSCLC; AP26113 is at the preclinicalstage; and LDK378 is developed by Novartis as the second-generation ALKinhibitor. NPM-ALK is a different variation/fusion of ALK that drivesanaplastic large-cell lymphomas (ALCLs) and is the target of other ALKinhibitors. Crizotinib has an aminopyridine structure, and functions asa protein kinase inhibitor by competitive binding within the ATP-bindingpocket of target kinases. About 4% of patients with non-small cell lungcarcinoma have a chromosomal rearrangement that generates a fusion genebetween EML4 (‘echinoderm microtubule-associated protein-like 4’) andALK (‘anaplastic lymphoma kinase’), which results in constitutive kinaseactivity that contributes to carcinogenesis and seems to drive themalignant phenotype. The kinase activity of the fusion protein isinhibited by crizotinib. Patients with this gene fusion are typicallyyounger non-smokers who do not have mutations in either the epidermalgrowth factor receptor gene (EGFR) or in the K-Ras gene. The number ofnew cases of ALK-fusion NSLC is about 9,000 per year in the U.S. andabout 45,000 worldwide. ALK mutations are thought to be important indriving the malignant phenotype in about 15% of cases of neuroblastoma,a rare form of peripheral nervous system cancer that occurs almostexclusively in very young children. Crizotinib inhibits thec-Met/Hepatocyte growth factor receptor (HGFR) tyrosine kinase, which isinvolved in the oncogenesis of a number of other histological forms ofmalignant neoplasms. Crizotinib is currently thought to exert itseffects through modulation of the growth, migration, and invasion ofmalignant cells. Other studies suggest that crizotinib might also actvia inhibition of angiogenesis in malignant tumors. Crizotinib causedtumors to shrink or stabilize in 90% of 82 patients carrying the ALKfusion gene. Tumors shrank at least 30% in 57% of people treated. Mosthad adenocarcinoma, and had never smoked or were former smokers. Theyhad undergone treatment with an average of three other drugs prior toreceiving crizotinib, and only 10% were expected to respond to standardtherapy. They were given 250 mg crizotinib twice daily for a medianduration of six months. Approximately 50% of these patients suffered atleast one side effect, such as nausea, vomiting, or diarrhea. Someresponses to crizotinib have lasted up to 15 months. A phase 3 trial,PROFILE 1007, compares crizotinib to standard second line chemotherapy(pemetrexed or taxotere) in the treatment of ALK-positive NSCLC.Additionally, a phase 2 trial, PROFILE 1005, studies patients meetingsimilar criteria who have received more than one line of priorchemotherapy. Crizotinib (Xalkori) is approved to treat certainlate-stage (locally advanced or metastatic) non-small cell lung cancersthat express the abnormal anaplastic lymphoma kinase (ALK) gene.Approval required a companion molecular test for the EML4-ALK fusion.

Another anti-cancer agent is Crizotinib. Crizotinib is also being testedin clinical trials of advanced disseminated anaplastic large-celllymphoma, and neuroblastoma.

An anti-cancer target includes Bcl-2 (B-cell lymphoma 2). Encoded by theBCL2 gene, is the founding member of the Bcl-2 family of regulatorproteins that regulate cell death (apoptosis). Bcl-2 derives its namefrom B-cell lymphoma 2, as it is the second member of a range ofproteins initially described in chromosomal translocations involvingchromosomes 14 and 18 in follicular lymphomas. Bcl-2 orthologs have beenidentified in numerous mammals for which complete genome data areavailable. The two isoforms of Bcl-2, Isoform 1, also known as 1G5M, andIsoform 2, also known as 1G50/1GJH, exhibit similar fold. However,results in the ability of these isoforms to bind to the BAD and BAKproteins, as well as in the structural topology and electrostaticpotential of the binding groove, suggest differences in antiapoptoticactivity for the two isoforms. Damage to the Bcl-2 gene has beenidentified as a cause of a number of cancers, including melanoma,breast, prostate, chronic lymphocytic leukemia, and lung cancer, and apossible cause of schizophrenia and autoimmunity. It is also a cause ofresistance to cancer treatments. Cancer occurs as the result of adisturbance in the homeostatic balance between cell growth and celldeath. Over-expression of anti-apoptotic genes, and under-expression ofpro-apoptotic genes, can result in the lack of cell death that ischaracteristic of cancer. An example can be seen in lymphomas. Theover-expression of the anti-apoptotic Bcl-2 protein in lymphocytes alonedoes not cause cancer. But simultaneous over-expression of Bcl-2 and theproto-oncogene myc may produce aggressive B-cell malignancies includinglymphoma. In follicular lymphoma, a chromosomal translocation commonlyoccurs between the fourteenth and the eighteenthchromosomes—t(14;18)—which places the Bcl-2 gene next to theimmunoglobulin heavy chain locus. This fusion gene is deregulated,leading to the transcription of excessively high levels of Bcl-2. Thisdecreases the propensity of these cells for undergoing apoptosis.Apoptosis also plays a very active role in regulating the immune system.When it is functional, it can cause immune unresponsiveness toself-antigens via both central and peripheral tolerance. In the case ofdefective apoptosis, it may contribute to etiological aspects ofautoimmune diseases. The autoimmune disease, type 1 diabetes can becaused by defective apoptosis, which leads to aberrant T cell AICD anddefective peripheral tolerance. Due to the fact that dendritic cells arethe most important antigen presenting cells of the immune system, theiractivity must be tightly regulated by such mechanisms as apoptosis.Researchers have found that mice containing dendritic cells that are Bim−/−, thus unable to induce effective apoptosis, obtain autoimmunediseases more so than those that have normal dendritic cells. Otherstudies have shown that the lifespan of dendritic cells may be partlycontrolled by a timer dependent on anti-apoptotic Bcl-2. Apoptosis playsa very important role in regulating a variety of diseases that haveenormous social impacts. For example, schizophrenia is aneurodegenerative disease that may result from an abnormal ratio of pro-and anti-apoptotic factors. There is some evidence that this defectiveapoptosis may result from abnormal expression of Bcl-2 and increasedexpression of caspase-3. Further research into the family of Bcl-2proteins will provide a more complete picture on how these proteinsinteract with each other to promote and inhibit apoptosis. Anunderstanding of the mechanisms involved may help develop new therapiesfor treating cancer, autoimmune conditions, and neurological diseases.Bcl-2 inhibitors include: An antisense oligonucleotide drug Genasense(G3139) that targets Bcl-2. An antisense DNA or RNA strand is non-codingand complementary to the coding strand (which is the template forproducing respectively RNA or protein). An antisense drug is a shortsequence of RNA that hybridises with and inactivates mRNA, preventingthe protein from being formed. It was shown that the proliferation ofhuman lymphoma cells (with t(14;18) translocation) could be inhibited byantisense RNA targeted at the start codon region of Bcl-2 mRNA. In vitrostudies led to the identification of Genasense, which is complementaryto the first 6 codons of Bcl-2 mRNA. Another BCL-2 inhibitor is ABT-73.ABT-73 is a novel inhibitor of Bcl-2, Bcl-xL and Bcl-w, known asABT-737. ABT-737 is one among many so-called BH3 mimetic small moleculeinhibitors (SMI) targeting Bcl-2 and Bcl-2-related proteins such asBcl-xL and Bcl-w but not A1 and Mcl-1, which may prove valuable in thetherapy of lymphoma and other blood cancers. Another inhibitor isABT-199. ABT-199 is a so-called BH3-mimetic drug designed to block thefunction of the Bcl-2 protein in patients with chronic lymphocyticleukemia. Another Bcl-2 inhibitors is obatoclax (GX15-070) forsmall-cell lung cancer. By inhibiting Bcl-2, Obatoclax induces apoptosisin cancer cells, preventing tumor growth.

Another family of anti-cancer agents are PARP inhibitors. PARPinhibitors are a group of pharmacological inhibitors of the enzyme polyADP ribose polymerase (PARP). They are developed for multipleindications; the most important is the treatment of cancer. Severalforms of cancer are more dependent on PARP than regular cells, makingPARP an attractive target for cancer therapy. In addition to their usein cancer therapy, PARP inhibitors are considered a potential treatmentfor acute life-threatening diseases, such as stroke and myocardialinfarction, as well as for long-term neurodegenerative diseases. DNA isdamaged thousands of times during each cell cycle, and that damage mustbe repaired. BRCA1, BRCA2 and PALB2 are proteins that are important forthe repair of double-strand DNA breaks by the error-free homologousrecombination repair, or HRR, pathway. When the gene for either proteinis mutated, the change can lead to errors in DNA repair that caneventually cause breast cancer. When subjected to enough damage at onetime, the altered gene can cause the death of the cells. PARP1 is aprotein that is important for repairing single-strand breaks (‘nicks’ inthe DNA). If such nicks persist unrepaired until DNA is replicated(which must precede cell division), then the replication itself cancause double strand breaks to form. Drugs that inhibit PARP1 causemultiple double strand breaks to form in this way, and in tumors withBRCA1, BRCA2 or PALB2 mutations these double strand breaks cannot beefficiently repaired, leading to the death of the cells. Normal cellsthat don't replicate their DNA as often as cancer cells, and that lacksany mutated BRCA1 or BRCA2 still have homologous repair operating, whichallows them to survive the inhibition of PARP. Some cancer cells thatlack the tumor suppressor PTEN may be sensitive to PARP inhibitorsbecause of down-regulation of Rad51, a critical homologous recombinationcomponent, although other data suggest PTEN may not regulate Rad51.Hence PARP inhibitors may be effective against many PTEN-defectivetumors (e.g. some aggressive prostate cancers). Cancer cells that arelow in oxygen (e.g. in fast growing tumors) are sensitive to PARPinhibitors. PARP inhibitors were originally thought to work primarily byblocking PARP enzyme activity, thus preventing the repair of DNA damageand ultimately causing cell death. PARP inhibitors have an additionalmode of action: localizing PARP proteins at sites of DNA damage, whichhas relevance to their anti-tumor activity. The trapped PARP protein-DNAcomplexes are highly toxic to cells because they block DNA replication.When the researchers tested three PARP inhibitors for their differentialability to trap PARP proteins on damaged DNA, they found that thetrapping potency of the inhibitors varied widely. The PARP family ofproteins in humans includes PARP1 and PARP2, which are DNA binding andrepair proteins. When activated by DNA damage, these proteins recruitother proteins that do the actual work of repairing DNA. Under normalconditions, PARP1 and PARP2 are released from DNA once the repairprocess is underway. However, as this study shows, when they are boundto PARP inhibitors, PARP1 and PARP2 become trapped on DNA. Theresearchers showed that trapped PARP-DNA complexes are more toxic tocells than the unrepaired single-strand DNA breaks that accumulate inthe absence of PARP activity, indicating that PARP inhibitors act asPARP poisons. These findings suggest that there may be two classes ofPARP inhibitors, catalytic inhibitors that act mainly to inhibit PARPenzyme activity and do not trap PARP proteins on DNA, and dualinhibitors that both block PARP enzyme activity and act as PARP poison.The main function of radiotherapy is to produce DNA strand breaks,causing severe DNA damage and leading to cell death. Radiotherapy hasthe potential to kill 100% of any targeted cells, but the dose requiredto do so would cause unacceptable side effects to healthy tissue.Radiotherapy therefore can only be given up to a certain level ofradiation exposure. Combining radiation therapy with PARP inhibitorsoffers promise, since the inhibitors would lead to formation of doublestrand breaks from the single-strand breaks generated by theradiotherapy in tumor tissue with BRCA1/BRCA2 mutations. Thiscombination could therefore lead to either more powerful therapy withthe same radiation dose or similarly powerful therapy with a lowerradiation dose. Examples of PARP inhibitors include: Iniparib (BSI 201)for breast cancer and squamous cell lung cancer; Olaparib (AZD-2281) forbreast, ovarian and colorectal cancer; Rucaparib (AG014699, PF-01367338)for metastatic breast and ovarian cancer; Veliparib (ABT-888) formetastatic melanoma and breast cancer; CEP 9722 for non-small-cell lungcancer (NSCLC); MK 4827 which inhibits both PARP1 and PARP2; BMN-673 foradvanced hematological malignancies and for advanced or recurrent solidtumors; and 3-aminobenzamide.

Another family of anti-cancer target is the PI3K/AKT/mTOR pathway. Thispathway is an important signaling pathway for many cellular functionssuch as growth control, metabolism and translation initiation. Withinthis pathway there are many valuable anti-cancer drug treatment targetsand for this reason it has been subject to a lot of research in recentyears. A Phosphoinositide 3-kinase inhibitor (PI3K inhibitor) is apotential medical drug that functions by inhibiting a Phosphoinositide3-kinase enzyme which is part of this pathway and therefore, throughinhibition, often results in tumor suppression. There are a number ofdifferent classes and isoforms of PI3Ks. Class 1 PI3Ks have a catalyticsubunit known as p110, with four types (isoforms)—p110 alpha, p110 beta,p110 gamma and p110 delta. The inhibitors being studied inhibit one ormore isoforms of the class I PI3Ks. They are being actively investigatedfor treatment of various cancers. Examples include: Wortmannin anirreversible inhibitor of PI3K; demethoxyviridin a derivative ofwortmannin; and LY294002 a reversible inhibitor of PI3K. Other PI3Kinhibitors include: Perifosine, for colorectal cancer and multiplemyeloma; CAL101 an oral PI3K delta for certain late-stage types ofleukemia's; PX-866; IPI-145, a novel inhibitor of PI3K delta and gamma,especially for hematologic malignancies; BAY 80-6946, predominantlyinhibiting PI3Kα,δ isoforms; BEZ235 a PI3K/mTOR dual inhibitor; RP6503,a dual PI3K delta/gamma inhibitor for the treatment of Asthma and COPD;TGR 1202, oral PI3K delta inhibitor (also known as RP5264); SF1126, thefirst PI3KI for B-cell chronic lymphocytic leukemia (CLL); INK1117, aPI3K-alpha inhibitor; GDC-0941 IC50 of 3 nM; BKM120; XL147 (also knownas SAR245408); XL765 (also known as SAR245409); Palomid 529; GSK1059615,where clinical trials were terminated due to lack of sufficient exposurefollowing single- and repeat-dosing; ZSTK474, a potent inhibitor againstp110a; PWT33597, a dual PI3K-alpha/mTOR inhibitor—for advanced solidtumors; IC87114 a selective inhibitor of p110δ. It has an IC50 of 100 nMfor inhibition of p110-δ; TG100-115, inhibits all four isoforms but hasa 5-10 fold better potency against p110-γ and p110-δ; CAL263; RP6530, adual PI3K delta/gamma inhibitor for T-cell Lymphomas; PI-103 a dualPI3K-mTOR inhibitor; GNE-477, a PI3K-alpha and mTOR inhibitor with IC50values of 4 nM and 21 nM; CUDC-907, also an HDAC inhibitor; andAEZS-136, which also inhibits Erk1/2.

Another anti-cancer agent is Apatinib. Also known as YN968D1, Apatinibis a tyrosine kinase inhibitor that selectively inhibits the vascularendothelial growth factor receptor-2 (VEGFR2, also known as KDR). It isan orally bioavailable, small molecule agent which is thought to inhibitangiogenesis in cancer cells; specifically apatinib inhibitsVEGF-mediated endothelial cell migration and proliferation thus blockingnew blood vessel formation in tumor tissue. This agent also mildlyinhibits c-Kit and c-SRC tyrosine kinases. Apatinib is aninvestigational cancer drug currently undergoing clinical trials as apotential targeted treatment for metastatic gastric carcinoma,metastatic breast cancer and advanced hepatocellular carcinoma. Cancerpatients were administered varied doses of Apatinib daily for 28 days.Apatinib was well tolerated at doses below 750 mg/day, 3 of 3 doselimiting toxicities were reported at 1000 mg/day and the maximumtolerated dose is determined to be 850 mg/day. The investigator alsoreported of 65 cancer patients treated in Phase I/II, 1.54% had acomplete response, 12.31% had a partial response, 66.15% had stabledisease and 20% had progressive disease. A separate published report onthe safety and pharmacokinetics of apatinib in Human clinical studiesconcludes that it has encouraging antitumor activity across a broadrange of cancer types. Some cancer cells have the ability to developresistance to the cytotoxic effects of certain cancer drugs (calledmultidrug resistance). A study concluded that apatinib may be useful incircumventing cancer cells' multidrug resistance to certain conventionalantineoplastic drugs. The study showed that apatinib reverses the ABCB1-and ABCG2-mediated multidrug resistance by inhibiting those functionsand increasing the intracellular concentrations of the antineoplasticdrugs. This study suggests that apatinib will be potentially effectivein combination therapies with conventional anticancer drugs especiallyin cases where resistance to chemotherapy exists.

Another family of anti-cancer target is BRAF. BRAF is a human gene thatencodes B-Raf. The gene is also referred to as proto-oncogene B-Raf andv-Raf murine sarcoma viral oncogene homolog B1, while the protein ismore formally known as serine/threonine-protein kinase B-Raf. The B-Rafprotein is involved in sending signals inside cells, which are involvedin directing cell growth. In 2002, it was shown to be faulty (mutated)in human cancers. Certain other inherited BRAF mutations cause birthdefects. Drugs that treat cancers driven by BRAF have been developed.Vemurafenib and dabrafenib are approved for late-stage melanoma. B-Rafis a member of the Raf kinase family of growth signal transductionprotein kinases. This protein plays a role in regulating the MAPkinase/ERKs signaling pathway, which affects cell division,differentiation, and secretion. B-Raf is a 766-amino acid, regulatedsignal transduction serine/threonine-specific protein kinase. Broadlyspeaking, it is composed of three conserved domains characteristic ofthe Raf kinase family: conserved region 1 (CR1), a Ras-GTP-bindingself-regulatory domain, conserved region 2 (CR2), a serine-rich hingeregion, and conserved region 3 (CR3), a catalytic protein kinase domainthat phosphorylates a consensus sequence on protein substrates. In itsactive conformation, B-Raf forms dimers via hydrogen-bonding andelectrostatic interactions of its kinase domains. B-Raf is aserine/threonine-specific protein kinase. As such, it catalyzes thephosphorylation of serine and threonine residues in a consensus sequenceon target proteins by ATP, yielding ADP and a phosphorylated protein asproducts. Since it is a highly regulated signal transduction kinase,B-Raf must first bind Ras-GTP before becoming active as an enzyme. OnceB-Raf is activated, a conserved protein kinase catalytic corephosphorylates protein substrates by promoting the nucleophilic attackof the activated substrate serine or threonine hydroxyl oxygen atom onthe γ-phosphate group of ATP through bimolecular nucleophilicsubstitution. To effectively catalyze protein phosphorylation via thebimolecular substitution of serine and threonine residues with ADP as aleaving group, B-Raf must first bind ATP and then stabilize thetransition state as the γ-phosphate of ATP is transferred. Sinceconstitutively active B-Raf mutants commonly cause cancer (see ClinicalSignificance) by excessively signaling cells to grow, inhibitors ofB-Raf have been developed for both the inactive and active conformationsof the kinase domain as cancer therapeutic candidates. BAY43-9006(Sorafenib, Nexavar) is a V600E mutant B-Raf and C-Raf inhibitorapproved by the FDA for the treatment of primary liver and kidneycancer. Bay43-9006 disables the B-Raf kinase domain by locking theenzyme in its inactive form. The inhibitor accomplishes this by blockingthe ATP binding pocket through high-affinity for the kinase domain. Itthen binds key activation loop and DFG motif residues to stop themovement of the activation loop and DFG motif to the activeconformation. Finally, a trifluoromethyl phenyl moiety sterically blocksthe DFG motif and activation loop active conformation site, making itimpossible for the kinase domain to shift conformation to become active.The distal pyridyl ring of BAY43-9006 anchors in the hydrophobicnucleotide-binding pocket of the kinase N-lobe, interacting with W531,F583, and F595. The hydrophobic interactions with catalytic loop F583and DFG motif F595 stabilize the inactive conformation of thesestructures, decreasing the likelihood of enzyme activation. Furtherhydrophobic interaction of K483, L514, and T529 with the center phenylring increase the affinity of the kinase domain for the inhibitor.Hydrophobic interaction of F595 with the center ring as well decreasesthe energetic favorability of a DFG conformation switch further.Finally, polar interactions of BAY43-9006 with the kinase domaincontinue this trend of increasing enzyme affinity for the inhibitor andstabilizing DFG residues in the inactive conformation. E501 and C532hydrogen bond the urea and pyridyl groups of the inhibitor respectivelywhile the urea carbonyl accepts a hydrogen bond from D594's backboneamide nitrogen to lock the DFG motif in place. The trifluoromethylphenyl moiety cements the thermodynamic favorability of the inactiveconformation when the kinase domain is bound to BAY43-9006 by stericallyblocking the hydrophobic pocket between the αC and αE helices that theDFG motif and activation loop would inhabit upon shifting to theirlocations in the active conformation of the protein. PLX4032(Vemurafenib) is a V600 mutant B-Raf inhibitor approved by the FDA forthe treatment of late-stage melanoma. Unlike BAY43-9006, which inhibitsthe inactive form of the kinase domain, Vemurafenib inhibits the active“DFG-in” form of the kinase, firmly anchoring itself in the ATP-bindingsite. By inhibiting only the active form of the kinase, Vemurafenibselectively inhibits the proliferation of cells with unregulated B-Raf,normally those that cause cancer. Since Vemurafenib only differs fromits precursor, PLX4720, in a phenyl ring added for pharmacokineticreasons, PLX4720's mode of action is equivalent to Vemurafenib's.PLX4720 has good affinity for the ATP binding site partially because itsanchor region, a 7-azaindole bicyclic, only differs from the naturaladenine that occupies the site in two places where nitrogen atoms havebeen replaced by carbon. This enables strong intermolecular interactionslike N7 hydrogen bonding to C532 and N1 hydrogen bonding to Q530 to bepreserved. Excellent fit within the ATP-binding hydrophobic pocket(C532, W531, T529, L514, A481) increases binding affinity as well.Ketone linker hydrogen bonding to water and difluoro-phenyl fit in asecond hydrophobic pocket (A481, V482, K483, V471, 1527, T529, L514, andF583) contribute to the exceptionally high binding affinity overall.Selective binding to active Raf is accomplished by the terminal propylgroup that binds to a Raf-selective pocket created by a shift of the αChelix. Selectivity for the active conformation of the kinase is furtherincreased by a pH-sensitive deprotonated sulfonamide group that isstabilized by hydrogen bonding with the backbone peptide NH of D594 inthe active state. In the inactive state, the inhibitor's sulfonamidegroup interacts with the backbone carbonyl of that residue instead,creating repulsion. Thus, Vemurafenib binds preferentially to the activestate of B-Rafs kinase domain. Mutations in the BRAF gene can causedisease in two ways. First, mutations can be inherited and cause birthdefects. Second, mutations can appear later in life and cause cancer, asan oncogene. Inherited mutations in this gene cause cardiofaciocutaneoussyndrome, a disease characterized by heart defects, mental retardationand a distinctive facial appearance. Acquired mutations in this genehave been found in cancers, including non-Hodgkin lymphoma, colorectalcancer, malignant melanoma, papillary thyroid carcinoma, non-small-celllung carcinoma, and adenocarcinoma of the lung. The V600E mutation ofthe BRAF gene has been associated with hairy cell leukemia in numerousstudies and has been suggested for use in screening for Lynch syndrometo reduce the number of patients undergoing unnecessary MLH1 sequencing.As mentioned above, some pharmaceutical firms are developing specificinhibitors of mutated B-raf protein for anticancer use because B-Raf isa well-understood, high yield target. Vemurafenib (RG7204 or PLX4032),licensed as Zelboraf for the treatment of metastatic melanoma, is thecurrent state-of-the-art example for why active B-Raf inhibitors arebeing pursued as drug candidates. Vemurafenib is biochemicallyinteresting as a mechanism to target cancer due to its high efficacy andselectivity. B-Raf not only increased metastatic melanoma patient chanceof survival but raised the response rate to treatment from 7-12% to 53%in the same amount of time compared to the former best chemotherapeutictreatment: dacarbazine. In spite of the drug's high efficacy, 20% oftumors still develop resistance to the treatment. In mice, 20% of tumorsbecome resistant after 56 days. While the mechanisms of this resistanceare still disputed, some hypotheses include the overexpression of B-Rafto compensate for high concentrations of Vemurafenib and upstreamupregulation of growth signaling. More general B-raf inhibitors includeGDC-0879, PLX-4720, Sorafenib Tosylate, Dabrafenib and LGX818.

Another family of anti-cancer agent is the MEK inhibitor. These are achemical or drug that inhibits the mitogen-activated protein kinasekinase enzymes MEK1 and/or MEK2. They can be used to affect the MAPK/ERKpathway which is often overactive in some cancers. Hence MEK inhibitorshave potential for treatment of some cancers, especially BRAF-mutatedmelanoma, and KRAS/BRAF mutated colorectal cancer. Examples of MEKinhibitors include: Trametinib (GSK1120212), for treatment ofBRAF-mutated melanoma and possible combination with BRAF inhibitordabrafenib to treat BRAF-mutated melanoma; Selumetinib, for non-smallcell lung cancer (NSCLC); MEK162, had phase 1 trial for biliary tractcancer and melanoma; PD-325901, for breast cancer, colon cancer, andmelanoma; XL518; CI-1040 and PD035901.

Another family of anti-cancer agent is the CDK (Cyclin-dependent kinase)inhibitor. CDK inhibitors are chemicals that inhibits the function ofCDKs. It is used to treat cancers by preventing overproliferation ofcancer cells. In many human cancers, CDKs are overactive orCDK-inhibiting proteins are not functional. Therefore, it is rational totarget CDK function to prevent unregulated proliferation of cancercells. However, the validity of CDK as a cancer target should becarefully assessed because genetic studies have revealed that knockoutof one specific type of CDK often does not affect proliferation of cellsor has an effect only in specific tissue types. For example, most adultcells in mice proliferate normally even without both CDK4 and CDK2.Furthermore, specific CDKs are only active in certain periods of thecell cycle. Therefore, the pharmacokinetics and dosing schedule of thecandidate compound must be carefully evaluated to maintain activeconcentration of the drug throughout the entire cell cycle. Types of CDKinhibitors include: Broad CDK inhibitors that target a broad spectrum ofCDKs; specific CDK inhibitors that target a specific type of CDK; andmultiple target inhibitors that target CDKs as well as additionalkinases such as VEGFR or PDGFR. Specific examples include: P1446A-05targeting CDK4 and PD-0332991 that targets CDK4 and CDK6 for leukemia,melanoma and solid tumors.

Another anti-cancer agent is Salinomycin. Salinomycin is anantibacterial and coccidiostat ionophore therapeutic drug. Salinomycinhas been shown to kill breast cancer stem cells in mice at least 100times more effectively than the anti-cancer drug paclitaxel. The studyscreened 16,000 different chemical compounds and found that only a smallsubset, including salinomycin and etoposide, targeted cancer stem cellsresponsible for metastasis and relapse. The mechanism of action by whichsalinomycin kills cancer stem cells specifically remains unknown, but isthought to be due to its action as a potassium ionophore due to thedetection of nigericin in the same compound screen. Studies performed in2011 showed that salinomycin could induce apoptosis of human cancercells. Promising results from a few clinical pilote studies reveal thatsalinomycin is able to effectively eliminate CSCs and to induce partialclinical regression of heavily pretreated and therapy-resistant cancers.The ability of salinomycin to kill both CSCs and therapy-resistantcancer cells may define the compound as a novel and an effectiveanticancer drug. It has been also shown that Salinomycin and itsderivatives exhibit potent antiproliferative activity against thedrug-resistant cancer cell lines. Salinomycin is the key compound in thepharmaceutical company Verastem's efforts to produce ananti-cancer-stem-cell drug.

Drugs for non-small cell lung cancer may include: Abitrexate(methotrexate), Abraxane (Paclitaxel Albumin-stabilized NanoparticleFormulation), Afatinib Dimaleate, Alimta (pemetrexed disodium), Avastin(Bevacizumab), Carboplatin, Cisplatin, Crizotinib, ErlotinibHydrochloride, Folex (methotrexate), Folex PFS (methotrexate), GefitinibGilotrif (afatinib dimaleate), Gemcitabine Hydrochloride, Gemzar(gemcitabine hydrochloride), Iressa (Gefitinib), Methotrexate,Methotrexate LPF (methotrexate), Mexate (methotrexate), Mexate-AQ(methotrexate), Paclitaxel, Paclitaxel Albumin-stabilized NanoparticleFormulation, Paraplat (carboplatin), Paraplatin (carboplatin),Pemetrexed Disodium, Platinol (cisplatin), Platinol-AQ (Cisplatin),Tarceva (Erlotinib Hydrochloride), Taxol (Paclitaxel), Taxotere orDocecad (docetaxel), and Xalkori (Crizotinib).

Combinations approved for non-small cell lung cancer may include:Carboplatin-Taxol and Gemcitabline-Cisplatin.

Drugs approved for small cell lung cancer may include: Abitrexate(methotrexate), Etopophos (etoposide phosphate), Etoposide, EtoposidePhosphate, Folex (methotrexate), Folex PFS (methotrexate), Hycamtin(topotecan hydrochloride), Methotrexate, Methotrexate LPF(methotrexate), Mexate (methotrexate), Mexate-AQ (methotrexate), Toposar(etoposide), Topotecan Hydrochloride, and VePesid (etoposide).

Aerosol administration directly to one or more desired regions of therespiratory tract, which includes the upper respiratory tract (e.g.,nasal, sinus, and pharyngeal compartments), the respiratory airways(e.g., laryngeal, tracheal, and bronchial compartments) and the lungs orpulmonary compartments (e.g., respiratory bronchioles, alveolar ducts,alveoli), may be effected (e.g., “pulmonary delivery”) in certainpreferred embodiments through intra-nasal or oral inhalation to obtainhigh and titrated concentration of drug, pro-drug active orsustained-release delivery to a site of respiratory pathology. Aerosoladministration such as by intra-nasal or oral inhalation may also beused to provide drug, pro-drug active or sustained-release deliverythrough the pulmonary vasculature (e.g., further to pulmonary delivery)to reach other tissues or organs, by non-limiting example, the heart,brain, liver central nervous system and/or kidney, with decreased riskof extra-respiratory toxicity associated with non-respiratory routes ofdrug delivery. Accordingly, because the efficacy of a particularpyridone compound (e.g., pirfenidone) therapeutic composition may varydepending on the formulation and delivery parameters, certainembodiments described herein reflect re-formulations of compositions andnovel delivery methods for recognized active drug compounds. Otherembodiments contemplate topical pathologies and/or infections that mayalso benefit from the discoveries described herein, for example, throughdirect exposure of a pirfenidone or pyridone analog compound formulationas provided herein to diseased skin, rectum, vagina, urethra, urinarybladder, eye, and/or ear, including aerosol delivery to a burn wound toprevent scarring.

In addition to the clinical and pharmacological criteria according towhich any composition intended for therapeutic administration (such asthe herein described pirfenidone or pyridone analog compoundformulations) may be characterized, those familiar with the art will beaware of a number of physicochemical factors unique to a given drugcomposition. These include, but are not limited to aqueous solubility,viscosity, partitioning coefficient (Log P), predicted stability invarious formulations, osmolality, surface tension, pH, pKa, pKb,dissolution rate, sputum permeability, sputum binding/inactivation,taste, throat irritability and acute tolerability.

Other factors to consider when selecting the particular product forminclude physical chemistry of the formulation (e.g., a pirfenidone orpyridone analog compound formulation), the intended diseaseindication(s) for which the formulation is to be used, clinicalacceptance, and patient compliance. As non-limiting examples, a desiredpirfenidone or pyridone analog compound formulation for aerosol delivery(e.g., by oral and/or intra-nasal inhalation of a mist such as anebulized suspension of liquid particles, a dispersion of a dry powderformulation or aerosol generated by meter-dose propellant), may beprovided in the form of a simple liquid such as an aqueous liquid (e.g.,soluble pirfenidone or pyridone analog compound with non-encapsulatingsoluble excipients/salts), a complex liquid such as an aqueous liquid(e.g., pirfenidone or pyridone analog compound encapsulated or complexedwith soluble excipients such as lipids, liposomes, cyclodextrins,microencapsulations, and emulsions), a complex suspension (e.g.,pirfenidone or pyridone analog compound as a low-solubility, stablenanosuspension alone, as co-crystal/co-precipitate complexes, and/or asmixtures with low solubility lipids such as solid-lipid nanoparticles),a dry powder (e.g., dry powder pirfenidone or pyridone analog compoundalone or in co-crystal/co-precipitate/spray-dried complex or mixturewith low solubility excipients/salts or readily soluble blends such aslactose), or an organic soluble or organic suspension solution, forpackaging and administration using an inhalation device such as ametered-dose inhalation device.

Selection of a particular pirfenidone or pyridone analog compoundformulation or pirfenidone or pyridone analog compound formulationcomposition as provided herein according to certain preferredembodiments may be influenced by the desired product packaging. Factorsto be considered in selecting packaging may include, for example,intrinsic product stability, whether the formulation may be subject tolyophilization, device selection (e.g., liquid nebulizer, dry-powderinhaler, meter-dose inhaler), and/or packaging form (e.g., simple liquidor complex liquid formulation, whether provided in a vial as a liquid oras a lyophilisate to be dissolved prior to or upon insertion into thedevice; complex suspension formulation whether provided in a vial as aliquid or as a lyophilisate, and with or without a solublesalt/excipient component to be dissolved prior to or upon insertion intothe device, or separate packaging of liquid and solid components; drypowder formulations in a vial, capsule or blister pack; and otherformulations packaged as readily soluble or low-solubility solid agentsin separate containers alone or together with readily soluble orlow-solubility solid agents.

Packaged agents may be manufactured in such a way as to be provide apirfenidone or pyridone analog compound formulation composition forpulmonary delivery that comprises a solution which is provided as apirfenidone or pyridone analog compound aqueous solution having a pHfrom about 3.0 to about 11.0, more preferably from about pH 4 to aboutpH 8, at a concentration of at least 0.1 mg/mL to about 50 mg/mL, andhaving a total osmolality at least 50 mOsmol/kg to about 1000 mOsmol/kg,more preferably 200 to about 500 mOsmol/kg.

In some embodiments, the present invention relates to the aerosol and/ortopical delivery of a pyridone analog compound (e.g., pirfenidone).Pirfenidone has favorable solubility characteristics enabling dosing ofclinically-desirable levels by aerosol (e.g., through liquidnebulization, dry powder dispersion or meter-dose administration) ortopically (e.g., aqueous suspension, oily preparation or the like or asa drip, spray, suppository, salve, or an ointment or the like), and canbe used in methods for acute or prophylactic treatment of a subjecthaving pulmonary fibrosis, or of a subject at risk for having pulmonaryfibrosis. Clinical criteria for determining when pulmonary fibrosis ispresent, or when a subject is at risk for having pulmonary fibrosis, areknown to the art. Pulmonary delivery via inhalation permits direct andtitrated dosing directly to the clinically-desired site with reducedsystemic exposure.

In a preferred embodiment, the method treats or serves as prophylaxisagainst interstitial lung disease (ILD) by administering a pirfenidoneor pyridone analog compound formulation as an aerosol (e.g., asuspension of liquid particles in air or another gas) to a subjecthaving or suspected to have interstitial lung disease. Interstitial lungdisease includes those conditions of idiopathic interstitial pneumoniasas defined by American Thoracic Society/European Respiratory Societyinternational multidisciplinary consensus classification of theidiopathic interstitial pneumonias, AM. J. Respir. Crit. Care Med. 165,277-304 (2002). These include ILD of known cause or association withconnective tissue diseases, occupational causes or drug side effect,idiopathic interstitial pneumonias (e.g. idiopathic pulmonary fibrosis,non-specific interstitial pneumonia, desquamative interstitialpneumonia, respiratory bronchiolitis-ILD, cryptogenic organizingpneumonia, acute interstitial pneumonia and lyphocytic interstitialpneumonia), granulomatous lung disease (e.g., sarcodosis, hypersensititypneumonitis and infection), and other forms of ILD (e.g.,lymphangioleiomyomatosis, pulmonary Langerhans' cell histocytosis,eosinophilic pneumonia and pulmonary alveolar proteinosis).

The therapeutic method may also include a diagnostic step, such asidentifying a subject with or suspected of having ILD. In someembodiments, the method further sub-classifies into idiopathic pulmonaryfibrosis. In some embodiments, the delivered amount of aerosolpirfenidone or pyridone analog compound (or salt thereof) formulation issufficient to provide acute, sub-acute, or chronic symptomatic relief,slowing of fibrosis progression, halting fibrosis progression, reversingfibrotic damage, and/or subsequent increase in survival and/or improvedquality of life.

The therapeutic method may also include a diagnostic step, such asidentifying a subject with or suspected of having fibrosis in othertissues, by non-limiting example in the heart, liver, kidney or skin. Insome embodiments, the delivered amount of liquid nebulized, dry powderor metered-dose aerosol pirfenidone or pyridone analog compound (or saltthereof) formulation is sufficient to provide acute, sub-acute, orchronic symptomatic relief, slowing of fibrosis progression, haltingfibrosis progression, reversing fibrotic damage, and/or subsequentincrease in survival and/or improved quality of life.

The therapeutic method may also include a diagnostic step, such asidentifying a subject with or suspected of having multiple sclerosis. Insome embodiments, the delivered amount of liquid nebulized, dry powderor metered-dose aerosol pirfenidone or pyridone analog compound (or saltthereof) formulation is sufficient to provide acute, sub-acute, orchronic symptomatic relief, slowing of demylination progression, haltingdemylination progression, reversing demylinated damage, and/orsubsequent increase in survival and/or improved quality of life.

In another embodiment, liquid nebulized, dry powder or metered-doseaerosol pirfenidone or pyridone analog compound (or salt thereof) may beco-administered, administered sequentially or prepared in afixed-combination with antimicrobial agents to also provide therapy fora co-existing bacterial infection. By non-limiting example the bacteriamay be a gram-negative bacteria such as Pseudomonas aeruginosa,Pseudomonas fluorescens, Pseudomonas acidovorans, Pseudomonasalcaligenes, Pseudomonas putida, Stenotrophomonas maltophilia,Burkholderia cepacia, Aeromonas hydrophilia, Escherichia coli,Citrobacter freundii, Salmonella typhimurium, Salmonella typhi,Salmonella paratyphi, Salmonella enteritidis, Shigella dysenteriae,Shigella flexneri, Shigella sonnei, Enterobacter cloacae, Enterobacteraerogenes, Klebsiella pneumoniae, Klebsiella oxytoca, Serratiamarcescens, Francisella tularensis, Morganella morganii, Proteusmirabilis, Proteus vulgaris, Providencia alcalifaciens, Providenciarettgeri, Providencia stuartii, Acinetobacter calcoaceticus,Acinetobacter haemolyticus, Yersinia enterocolitica, Yersinia pestis,Yersinia pseudotuberculosis, Yersinia intermedia, Bordetella pertussis,Bordetella parapertussis, Bordetella bronchiseptica, Haemophilusinfluenzae, Haemophilus parainfluenzae, Haemophilus haemolyticus,Haemophilus parahaemolyticus, Haemophilus ducreyi, Pasteurellamultocida, Pasteurella haemolytica, Branhamella catarrhalis,Helicobacter pylori, Campylobacter fetus, Campylobacter jejuni,Campylobacter coli, Borrelia burgdorferi, Vibrio cholerae, Vibrioparahaemolyticus, Legionella pneumophila, Listeria monocytogenes,Neisseria gonorrhoeae, Neisseria meningitidis, Kingella, Moraxella,Gardnerella vaginalis, Bacteroides fragilis, Bacteroides distasonis,Bacteroides 3452A homology group, Bacteroides vulgatus, Bacteroidesovalus, Bacteroides thetaiotaomicron, Bacteroides uniformis, Bacteroideseggerthii, and Bacteroides splanchnicus. In some embodiments of themethods described above, the bacteria are gram-negative anaerobicbacteria, by non-limiting example these include Bacteroides fragilis,Bacteroides distasonis, Bacteroides 3452A homology group, Bacteroidesvulgatus, Bacteroides ovalus, Bacteroides thetaiotaomicron, Bacteroidesuniformis, Bacteroides eggerthii, and Bacteroides splanchnicus. In someembodiments of the methods described above, the bacteria aregram-positive bacteria, by non-limiting example these include:Corynebacterium diphtheriae, Corynebacterium ulcerans, Streptococcuspneumoniae, Streptococcus agalactiae, Streptococcus pyogenes,Streptococcus milleri; Streptococcus (Group G); Streptococcus (GroupC/F); Enterococcus faecalis, Enterococcus faecium, Staphylococcusaureus, Staphylococcus epidermidis, Staphylococcus saprophyticus,Staphylococcus intermedius, Staphylococcus hyicus subsp. hyicus,Staphylococcus haemolyticus, Staphylococcus hominis, and Staphylococcussaccharolyticus. In some embodiments of the methods described above, thebacteria are gram-positive anaerobic bacteria, by non-limiting examplethese include Clostridium difficile, Clostridium perfringens,Clostridium tetini, and Clostridium botulinum. In some embodiments ofthe methods described above, the bacteria are acid-fast bacteria, bynon-limiting example these include Mycobacterium tuberculosis,Mycobacterium avium, Mycobacterium intracellulare, and Mycobacteriumleprae. In some embodiments of the methods described above, the bacteriaare atypical bacteria, by non-limiting example these include Chlamydiapneumoniae and Mycoplasma pneumoniae.

As a non-limiting example, in a preferred embodiment, a pyridone analogcompound as provided herein (e.g., pirfenidone) formulated to permitmist, gas-liquid suspension or liquid nebulized, dry powder and/ormetered-dose inhaled aerosol administration to supply effectiveconcentrations or amounts to produce and maintain threshold drugconcentrations in the lung and/or targeted downstream tissue, which maybe measured as drug levels in epithelial lining fluid (ELF), sputum,lung tissue, bronchial lavage fluid (BAL), or by deconvolution of bloodconcentrations through pharmacokinetic analysis. One embodiment includesthe use of aerosol administration, delivering high or titratedconcentration drug exposure directly to the affected tissue fortreatment of pulmonary fibrosis and inflammation associated with ILD(including idiopathic pulmonary fibrosis), COPD and asthma in animalsand humans. In one such embodiment, the peak lung ELF levels achievedfollowing aerosol administration to the lung will be between 0.1 mg/mLand about 50 mg/mL pirfenidone or pyridone analog. In anotherembodiment, the peak lung wet tissue levels achieved following aerosoladministration to the lung will be between 0.004 mcg/gram lung tissueand about 500 mcg/gram lung tissue pirfenidone or pyridone analog.

As a non-limiting example, in a preferred embodiment, a pyridone analogcompound as provided herein (e.g., pirfenidone) formulated to permitmist, gas-liquid suspension or liquid nebulized, dry powder and/ormetered-dose inhaled aerosol administration to supply effectiveconcentrations or amounts to produce and maintain threshold drugconcentrations in the blood and/or lung, which may be measured as druglevels in epithelial lining fluid (ELF), sputum, lung tissue, bronchiallavage fluid (BAL), or by deconvolution of blood concentrations throughpharmacokinetic analysis that absorb to the pulmonary vasculatureproducing drug levels sufficient for extra-pulmonary therapeutics,maintenance or prophylaxis. One embodiment includes the use of aerosoladministration, delivering high concentration drug exposure in thepulmonary vasculature and subsequent tissues and associated vasculaturefor treatment, maintenance and/or prophylaxis of, but not limited tocardiac fibrosis, kidney fibrosis, hepatic fibrosis, heart or kidneytoxicity, or multiple sclerosis. In one such embodiment, the peaktissue-specific plasma levels (e.g., heart, kidney and liver) orcerebral spinal fluid levels (e.g. central nervous system) achievedfollowing aerosol administration to the lung following oral inhalationor to the lung or nasal cavity following intra-nasal administration willbe between 0.1 mcg/mL and about 50 mcg/mL pirfenidone or pyridoneanalog. In another embodiment, the peak lung wet tissue levels achievedfollowing aerosol administration to the lung will be between 0.004mcg/gram lung tissue and about 500 mcg/gram lung tissue pirfenidone orpyridone analog.

In another embodiment, a method is provided for acute or prophylactictreatment of a patient through non-oral or non-nasal topicaladministration of pirfenidone or pyridone analog (or a salt thereof)compound formulation to produce and maintain threshold drugconcentrations at a burn site. One embodiment includes the use ofaerosol administration, delivering high concentration drug exposuredirectly to the affected tissue for treatment or prevention of scarringin skin. For example according to these and related embodiments, theterm aerosol may include a spray, mist, or other nucleated liquid or drypowder form.

In another embodiment, a method is provided for acute or prophylactictreatment of a patient through non-oral or non-nasal topicaladministration of pirfenidone or pyridone analog (or a salt thereof)compound formulation to produce and maintain threshold drugconcentrations in the eye. One embodiment includes the use of aerosoladministration or formulation drops to deliver high concentration drugexposure directly to the affected tissue for treatment or prevention ofscarring following surgical glaucoma surgery (e.g., bleb fibrosis). Forexample according to these and related embodiments, the term aerosol mayinclude a spray, mist, or other nucleated liquid or dry powder form. Adrop may be simple liquid or suspension formulation.

In another embodiment, a pyridone analog compound as provided herein(e.g., pirfenidone) formulation by inhalation, wherein the inhaledliquid aerosol (e.g., following liquid nebulization or metered-doseadministration) or dry powder aerosol has a mean particle size fromabout 1 micron to 10 microns mass median aerodynamic diameter and aparticle size geometric standard deviation of less than or equal toabout 3 microns. In another embodiment, the particle size is 2 micronsto about 5 microns mass median aerodynamic diameter and a particle sizegeometric standard deviation of less than or equal to about 3 microns.In one embodiment, the particle size geometric standard deviation isless than or equal to about 2 microns.

As a non-limiting example, in a preferred embodiment, a pyridone analogcompound as provided herein (e.g., pirfenidone) remains at thetherapeutically effective concentration at the site of pulmonarypathology, suspected pulmonary pathology, and/or site of pulmonaryabsorption into the pulmonary vasculature for at least about 1 minute,at least about a 5 minute period, at least about a 10 min period, atleast about a 20 min period, at least about a 30 min period, at leastabout a 1 hour period, at least a 2 hour period, at least about a 4 hourperiod, at least an 8 hour period, at least a 12 hour period, at least a24 hour period, at least a 48 hour period, at least a 72 hour period, orat least one week. The effective pirfenidone or pyridone analogconcentration is sufficient to cause a therapeutic effect and the effectmay be localized or broad-acting to or from the site of pulmonarypathology.

As a non-limiting example, in a preferred embodiment, a pyridone analogcompound as provided herein (e.g., pirfenidone or salt thereof)following inhalation administration remains at the therapeuticallyeffective concentration at the site of cardiac fibrosis, kidneyfibrosis, hepatic fibrosis, heart or kidney toxicity, or multiplesclerosis demylination for at least about 1 minute, at least about a 5minute period, at least about a 10 min period, at least about a 20 minperiod, at least about a 30 min period, at least about a 1 hour period,at least a 2 hour period, at least about a 4 hour period, at least an 8hour period, at least a 12 hour period, at least a 24 hour period, atleast a 48 hour period, at least a 72 hour period, or at least one week.The effective pirfenidone or pyridone analog concentration is sufficientto cause a therapeutic effect and the effect may be localized orbroad-acting to or from the site of extrapulmonary pathology.

In some embodiments, delivery sites such as a pulmonary site, the apirfenidone or pyridone analog compound formulation as provided hereinis administered in one or more administrations so as to achieve arespirable delivered dose daily of pirfenidone or pyridone analog of atleast about 0.1 mg to about 50 mg, including all integral values thereinsuch as 0.1, 0.2, 0.4, 0.8, 1, 2, 4, 6, 10, 15, 20, 25, 30, 35, 40, 45,50 milligrams. In some embodiments, a pirfenidone or pyridone analogcompound formulation as provided herein is administered in one or moreadministrations so as to achieve a respirable delivered dose daily ofpirfenidone or pyridone analog of at least about 0.1 mg to about 300 mg,including all integral values therein such as 0.1, 0.2, 0.4, 0.8, 1, 2,4, 6, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85,90, 95, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155,160, 165, 170, 175, 180, 185, 190, 195, 200, 205, 210, 215, 220, 225,230, 235, 240, 245, 250, 255, 260, 265, 270, 275, 280, 285, 290, 295,300 milligrams. The pirfenidone or pyridone analog formulation isadministered in the described respirable delivered dose in less than 60minutes, less than 50 minutes, less than 40 minutes, less than 30minutes, less than 20 minutes, less than 15 minutes, less than 10minutes, less than 7 minutes, less than 5 minutes, in less than 3minutes, in less than 2 minutes, in less than 1 minute, 10 inhalationbreaths, 8 inhalation breaths, 6 inhalation breaths, 4 inhalationbreaths, 3 inhalation breaths, 2 inhalation breaths or 1 inhalationbreath. In some embodiments, pirfenidone or pyridone analog formulationis administered in the described respirable delivered dose using abreathing pattern of 1 second inhalation and 2 seconds exhalation, 2seconds inhalation and 2 seconds exhalation, 3 seconds inhalation and 2seconds exhalation, 4 seconds inhalation and 2 seconds exhalation, 5seconds inhalation and 2 seconds exhalation, 6 seconds inhalation and 2seconds exhalation, 7 seconds inhalation and 2 seconds exhalation, and 8seconds inhalation and 2 seconds exhalation.

In some embodiments, delivery sites such as the nasal cavity or sinus,pirfenidone or pyridone analog (or salt thereof) compound formulation isadministered in one or more administrations so as to achieve a nasalcavity or sinus deposited dose daily of pirfenidone or pyridone analogof at least about 0.1 mg to about 50 mg, including all integral valuestherein such as 0.1, 0.2, 0.4, 0.8, 1, 2, 4, 6, 10, 15, 20, 25, 30, 35,40, 45, 50 milligrams. In some embodiments, delivery sites such as thenasal cavity or sinus, pirfenidone or pyridone analog (or salt thereof)compound formulation is administered in one or more administrations soas to achieve a nasal cavity or sinus deposited dose daily ofpirfenidone or pyridone analog of at least about 0.1 mg to about 300 mg,including all integral values therein such as 0.1, 0.2, 0.4, 0.8, 1, 2,4, 6, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85,90, 95, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155,160, 165, 170, 175, 180, 185, 190, 195, 200, 205, 210, 215, 220, 225,230, 235, 240, 245, 250, 255, 260, 265, 270, 275, 280, 285, 290, 295,300 milligrams. The pirfenidone or pyridone analog formulation isadministered in the described nasal or sinus deposited dose in less than20 minutes, less than 15 minutes, less than 10 minutes, less than 7minutes, less than 5 minutes, in less than 3 minutes, in less than 2minutes, in less than 1 minute, 10 intranasal inhalation breaths, 8intranasal inhalation breaths, 6 intranasal inhalation breaths, 4intranasal inhalation breaths, 3 intranasal inhalation breaths, 2intranasal inhalation breaths or 1 intranasal inhalation breath. In someembodiments, pirfenidone or pyridone analog formulation is administeredin the described respirable delivered dose using a breathing pattern of1 second inhalation and 2 seconds exhalation, 2 seconds inhalation and 2seconds exhalation, 3 seconds inhalation and 2 seconds exhalation, 4seconds inhalation and 2 seconds exhalation, 5 seconds inhalation and 2seconds exhalation, 6 seconds inhalation and 2 seconds exhalation, 7seconds inhalation and 2 seconds exhalation, and 8 seconds inhalationand 2 seconds exhalation.

In some embodiments of the methods described above, the subject is ahuman. In some embodiments of the methods described above, the subjectis a human with ILD. In some embodiments, the method furthersub-classifies into idiopathic pulmonary fibrosis. In some embodimentsof the methods describe above, the human subject may be mechanicallyventilated.

In embodiments where a human is mechanically ventilated, aerosoladministration would be performed using an in-line device (bynon-limiting example, the Nektar Aeroneb Pro) or similar adaptor withdevice for liquid nebulization. Aerosol administration could also beperformed using an in-line adaptor for dry powder or metered-doseaerosol generation and delivery.

In some embodiments of the methods described above, the subject is ahuman. In some embodiments of the methods described above, the subjectis a human requiring cardiac fibrosis therapy. In some embodiments ofthe methods describe above, the human subject may be mechanicallyventilated.

In some embodiments of the methods described above, the subject is ahuman. In some embodiments of the methods described above, the subjectis a human requiring kidney fibrosis therapy. In some embodiments of themethods describe above, the human subject may be mechanicallyventilated.

In some embodiments of the methods described above, the subject is ahuman. In some embodiments of the methods described above, the subjectis a human requiring hepatic fibrosis therapy. In some embodiments ofthe methods describe above, the human subject may be mechanicallyventilated.

In some embodiments of the methods described above, the subject is ahuman. In some embodiments of the methods described above, the subjectis a human requiring cardiac or kidney toxicity therapy. In someembodiments of the methods describe above, the human subject may bemechanically ventilated.

In some embodiments of the methods described above, the subject is ahuman. In some embodiments of the methods described above, the subjectis a human requiring COPD therapy. In some embodiments of the methodsdescribe above, the human subject may be mechanically ventilated.

In some embodiments of the methods described above, the subject is ahuman. In some embodiments of the methods described above, the subjectis a human requiring asthma therapy. In some embodiments of the methodsdescribe above, the human subject may be mechanically ventilated.

In some embodiments of the methods described above, the subject is ahuman. In some embodiments of the methods described above, the subjectis a human requiring multiple sclerosis therapy. In some embodiments ofthe methods describe above, the human subject may be mechanicallyventilated.

In another embodiment, a pharmaceutical composition is provided thatincludes a simple liquid pirfenidone or pyridone analog (or saltthereof) compound formulation with non-encapsulating water solubleexcipients as described above having an osmolality from about 50mOsmol/kg to about 6000 mOsmol/kg. In one embodiment, the osmolality isfrom about 50 mOsmol/kg to about 1000 mOsmol/kg. In one embodiment, theosmolality is from about 400 mOsmol/kg to about 5000 mOsmol/kg. In otherembodiments the osmolality is from about 50, 100, 150, 200, 250, 300,350, 400, 450, 500 mOsmol/kg to about 1000, 1100, 1200, 1300, 1400,1500, 1600, 1700, 1800, 1900, 2000, 2200, 2400, 2600, 2800, 3000, 3200,3400, 3600, 3800, 4000, 4200, 4400, 4600, 4800 m 5000, 5200, 5400, 5600,5800 and 6000 mOsmol/kg. With respect to osmolality, and also elsewherein the present application, “about” when used to refer to a quantitativevalue means that a specified quantity may be greater than or less thanthe indicated amount by 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14,15, 16, 17, 18, 19 or 20 percent of the stated numerical value.

In another embodiment, a pharmaceutical composition is provided thatincludes a simple liquid pirfenidone or pyridone analog (or saltthereof) compound formulation having a permeant ion concentrationbetween from about 30 mM to about 300 mM and preferably between fromabout 50 mM to 200 mM. In one such embodiment, one or more permeant ionsin the composition are selected from the group consisting of chlorideand bromide.

In another embodiment, a pharmaceutical composition is provided thatincludes a complex liquid pirfenidone or pyridone analog (or saltthereof) compound formulation encapsulated or complexed with watersoluble excipients such as lipids, liposomes, cyclodextrins,microencapsulations, and emulsions) as described above having a solutionosmolality from about 50 mOsmol/kg to about 6000 mOsmol/kg. In oneembodiment, the osmolality is from about 50 mOsmol/kg to about 1000mOsmol/kg. In one embodiment, the osmolality is from about 100 mOsmol/kgto about 500 mOsmol/kg. In one embodiment, the osmolality is from about400 mOsmol/kg to about 5000 mOsmol/kg.

In another embodiment, a pharmaceutical composition is provided thatincludes a complex liquid pirfenidone or pyridone analog (or saltthereof) compound formulation having a permeant ion concentration fromabout 30 mM to about 300 mM. In one such embodiment, one or morepermeant ions in the composition are selected from the group consistingof chloride and bromide.

In another embodiment, a pharmaceutical composition is provided thatincludes a complex liquid pirfenidone or pyridone analog (or saltthereof) compound formulation having a permeant ion concentration fromabout 50 mM to about 200 mM. In one such embodiment, one or morepermeant ions in the composition are selected from the group consistingof chloride and bromide.

In another embodiment, a pharmaceutical composition is provided thatincludes a simple liquid formulation of pirfenidone or pyridone analog(or salt thereof) compound formulation having a prifenidone or pyridoneanalog to multivalent cation positive charge molar ratio between abouttwo pirfenidone or pyridone analog compounds to about 0.1 to about 4multivalent cation positive charges. By non-limiting example, twopirfenidone or pyridone analog compounds to one magnesium ion (twocation positive charges), three prifenidone or pyridone analog compoundsto one magnesium ions, four pirfenidone or pyridone analog compounds toone magnesium ions, and two pirfenidone or pyridone analog compounds totwo magnesium ions.

An unexpected finding was that divalent cations, by non-limiting examplemagnesium, reduced pirfenidone dissolution time and increasedpirfenidone aqueous solubility in a molar ratio-dependent manner. Thisincreased saturation solubility is enabling to deliverpredicted-sufficient quantities of inhaled liquid-nebulized pirfenidoneto the lung. By example, one pirfenidone molecules to three magnesiummolecules exhibited a slower dissolution time and reduced saturationsolubility than one pirfenidone molecule to one magnesium molecule.Moreover, one pirfenidone molecules to one magnesium molecule exhibiteda faster dissolution time and greater aqueous solubility than anequal-molar ratio of pirfenidone to sodium.

In another embodiment, a pharmaceutical composition is provided thatincludes a complex liquid formulation of pirfenidone or pyridone analog(or salt thereof) compound formulation having a prifenidone or pyridoneanalog to about 0.1 to about 4 multivalent cation positive charges. Bynon-limiting example, two pirfenidone or pyridone analog compounds toone magnesium ion (two cation positive charges), three prifenidone orpyridone analog compounds to one magnesium ions, four pirfenidone orpyridone analog compounds to one magnesium ions, and two pirfenidone orpyridone analog compounds to two magnesium ions.

In another embodiment, a pharmaceutical composition is provided thatincludes a complex liquid pirfenidone or pyridone analog (or saltthereof) compound formulation as a low water-soluble stablenanosuspension alone or in co-crystal/co-precipitate complexes, ormixtures with low solubility lipids, such as lipid nanosuspensions) asdescribed above having a solution osmolality from about 50 mOsmol/kg toabout 6000 mOsmol/kg. In one embodiment, the osmolality is from about100 mOsmol/kg to about 500 mOsmol/kg. In one embodiment, the osmolalityis from about 400 mOsmol/kg to about 5000 mOsmol/kg.

In another embodiment, a pharmaceutical composition is provided thatincludes a complex suspension of a pirfenidone or pyridone analog (orsalt thereof) compound formulation having a permeant ion concentrationfrom about 30 mM to about 300 mM. In one such embodiment, one or morepermeant ions in the composition are selected from the group consistingof chloride and bromide.

In another embodiment, a pharmaceutical composition is provided thatincludes a complex suspension of a pirfenidone or pyridone analog (orsalt thereof) compound formulation having a permeant ion concentrationfrom about 50 mM to about 200 mM. In one such embodiment, one or morepermeant ions in the composition are selected from the group consistingof chloride and bromide.

In another embodiment, a pharmaceutical composition is provided thatincludes a complex suspension of pirfenidone or pyridone analog (or saltthereof) compound formulation having a pirfenidone or pyridone analog tomultivalent cation positive charge molar ratio between about onepirfenidone or pyridone analog compounds to about 0.1 to about 4multivalent cation positive charges. By non-limiting example, twopirfenidone or pyridone analog compounds to one magnesium ion (twocation positive charges), three prifenidone or pyridone analog compoundsto one magnesium ions, four pirfenidone or pyridone analog compounds toone magnesium ions, and two pirfenidone or pyridone analog compounds totwo magnesium ions.

In other embodiments, a pirfenidone or pyridone analog (or salt thereof)compound formulation as provided herein, or a pharmaceuticalcomposition, is provided that includes a taste-masking agent. Asnon-limiting examples, a taste-masking agent may include a sugar,saccharin (e.g., sodium saccharin), sweetener or other compound or agentthat beneficially affects taste, after-taste, perceived unpleasantsaltiness, sourness or bitterness, or that reduces the tendency of anoral or inhaled formulation to irritate a recipient (e.g., by causingcoughing or sore throat or other undesired side effect, such as mayreduce the delivered dose or adversely influence patient compliance witha prescribed therapeutic regimen). Certain taste-masking agents may formcomplexes with a pirfenidone or pyridone analog (or salt thereof)compound.

In certain preferred embodiments that relate to the pirfenidone orpyridone analog (or salt thereof) compound formulations disclosedherein, the formulation comprises a pirfenidone or pyridone analog (orsalt thereof) compound and a taste-masking agent and may be optimizedwith respect to a desired osmolality, and/or an optimized permeant ionconcentration. In certain such embodiments, the taste-masking agentcomprises saccharin (e.g., sodium saccharin), which according tonon-limiting theory affords certain advantages associated with theability of this taste-masking agent to provide desirable taste effectseven when present in extremely low concentrations, such as may havelittle or no effect on the detectable osmolality of a solution, therebypermitting the herein described formulations to deliver aqueoussolutions, organic or dry powder formulations in a well-toleratedmanner. In certain such embodiments, the taste-masking agent comprises achelating agent (e.g., EDTA or divalent cation such as magnesium), whichaccording to non-limiting theory affords certain advantages associatedwith the ability of this taste-masking agent to provide desirable tasteeffects by masking taste-stimulating chemical moieties on pirfenidone ofpyridone analog. With divalent cations, inclusion as a taste-maskingagent may also substitute as an osmolality adjusting agent, and pendingthe salt form may also provide the permeant ion (e.g. magnesiumchloride), thereby permitting the herein described formulations todeliver aqueous solutions, organic or dry powder formulations in awell-tolerated manner. Non-limiting examples of these and relatedembodiments include a pirfenidone or pyridone analog (or salt thereof)compound formulation for pulmonary delivery as described herein thatcomprises an aqueous solution having a pH of from about 4 to about 8 andan osmolality of from about 50 to about 1000 mOsmol/kg (e.g., adjustedwith sodium chloride), the solution comprising pirfenidone or pyridoneanalog (or salt thereof) compound and sodium saccharin where the aqueoussolution contains from about 0.1 mM to about 2.0 mM saccharin. A relatednon-limiting example further comprises citrate (e.g., citric acid) in anaqueous solution containing from about 1 mM to about 100 mM citrate. Arelated non-limiting example further comprises or replace citrate withphosphate (e.g., sodium phosphate) in an aqueous solution containingfrom about 0.0 mM to about 100 mM phosphate. Another relatednon-limiting example further comprises or replace citrate with phosphate(e.g., sodium phosphate) in an aqueous solution containing from about0.5 mM to about 100 mM phosphate. By another non-limiting examples,these and related embodiments include a pirfenidone or pyridone analog(or salt thereof) compound formulation for pulmonary delivery asdescribed herein that comprises an aqueous solution having a pH of fromabout 4 to about 8 and an osmolality of from about 50 to about 5000mOsmol/kg (e.g., adjusted with magnesium chloride), the solutioncomprising pirfenidone or pyridone analog (or salt thereof) compound,wherein a divalent cation (e.g., berilium, magnesium, or calcium) servesboth to adjust osmolality and as a taste-masking agent. Where includedas a taste-masking agent, divalent cation (e.g., magnesium) is addedstoichiometrically with pirfenidone or pyridone analog. By example, 1mol divalent ion to 2 mols pirfenidone or pyridone analog, 1.5 molsdivalent ion to 2 mols pirfenidone or pyridone analog, 2 mols divalention to 2 mols pirfenidone or pyridone analog, 3 mols divalent ion to 2mols pirfenidone or pyridone analog, or 4 mols divalent ion to 2 molspirfenidone or pyridone analog. Where osmolality required furtherincrease sodium chloride or additional divalent salt may be used. Arelated non-limiting example further comprises citrate (e.g., citricacid) in an aqueous solution containing from about 1 mM to about 100 mMcitrate. A related non-limiting example citrate is replaced withphosphate (e.g., sodium phosphate) in an aqueous solution containingfrom about 0.0 mM to about 100 mM phosphate. In another relatednon-limiting example citrate is replaced with phosphate (e.g., sodiumphosphate) in an aqueous solution containing from about 0.0 mM to about100 mM phosphate.

In another embodiment, while the inclusion of the correct molar ratio ofmagnesium to pirfenidone reduces dissolution time and increasessaturation solubility to a level required for sufficient liquidnebulization delivery to the lung, an unexpected finding was that thisformulation additionally requires a taste masking agent for acutetolerability upon inhalation of a nebulized solution. To this end,between 0.1 and 1.0 micromolar saccharin enables the use of thissolubility-enabling formulation.

In another embodiment, a pharmaceutical composition may be protectedfrom light to avoid photodegradation. By non-limiting example, this mayoccur by light-protected vials, ampoules, blisters, capsules, or othercolored or light-protected primary packaging. By another non-limitingexample, this may occur by use of secondary packaging such as analuminum or other light-protected over-pouch, box or other secondarypackaging.

In another embodiment, a pharmaceutical composition may be protectedfrom oxygen to protect from oxidation. By non-limiting example, insolution this may occur by removing oxygen from solution prior to orduring compounding (e.g., sparging), and or controlled the primarypackaging head-space gas (e.g. using of inert gas such as argon ornitrogen in the head space). Similarly, by another non-limiting example,controlling the included secondary packaging gas (e.g. with inert gas)may also be required. For powder formulations this may be controlled byuse of insert gas in primary and/or secondary packaging. Meter-doseinhaled products may benefit by the same means as described above forsolution products.

In another embodiment, pirfenidone or pyridone analog present in apharmaceutical composition may be protected from hydrolysis by inclusionof a cationic metal ion. By non-limiting example, acid hydrolysis ofamide bonds decreases with an increased salt concentration.Specifically, hydration number is important for this rate decrease, aselectrolyte hydration decreases the availability of free water for thereaction. Thus, the rate decreases with increased salt and increasedhydration number. The order of increasing hydration number:potassium<sodium<lithium<magnesium. The rate decrease also nearlyparallels ionic strength. By non-limiting example, the addition ofmagnesium will stabilize the 2-pyridone structure of pirfenidone. It isknown that pirfenidone chelates Fe(III) at a ratio of 3 pirfenidonemolecules to 1 Fe(III). From this it follows that pirfenidone willchelate magnesium at 2 pirfenidone molecules to 1 magnesium+2 charge.Therefore, for this purpose the addition of magnesium or other cationicmetal ion may be stoichiometric to the amount of pirfenidone or pyridoneanalog. By non-limiting example, 2 pirfenidone molecules to 0.1magnesium molecules, 2 pirfenidone molecules to 0.25 magnesiummolecules, 2 pirfenidone molecules to 0.5 magnesium molecules, 2pirfenidone molecules to 0.75 magnesium molecules, 2 pirfenidonemolecules to 1 magnesium molecules, 2 pirfenidone molecules to 1.5magnesium molecules, 2 pirfenidone molecules to 2 magnesium molecules, 2pirfenidone molecules to 3 magnesium molecules, 2 pirfenidone moleculesto 4 magnesium molecules, 2 pirfenidone molecules to 5 magnesiummolecules, 2 pirfenidone molecules to 6 magnesium molecules, 2pirfenidone molecules to 7 magnesium molecules, 2 pirfenidone moleculesto 8 magnesium molecules, 2 pirfenidone molecules to 9 magnesiummolecules, 2 pirfenidone molecules to 10 magnesium molecules, 2pirfenidone molecules to 12 magnesium molecules, 2 pirfenidone moleculesto 14 magnesium molecules, 2 pirfenidone molecules to 16 magnesiummolecules, 2 pirfenidone molecules to 18 magnesium molecules, or 2pirfenidone molecules to 20 magnesium molecules. Potassium, sodium,lithium or iron may substitute for magnesium in these ratios andpharmaceutical composition. Included in the above pharmaceuticalcomposition is the maintenance of the buffers described herein, at a pHfrom about 4.0 to about 8.0, and include MgCl2 or cationic salt thereofat a level that provides an osmolality of 300 mOsmo/kg and 600 mOsmo/kg.While 300 mOsmo/kg is discussed in the literature as important for acutetolerability upon inhalation of this in a nebulized solution, 600mOsmo/kg has been shown in unpublished studies to be well tolerated withother drug solutions. However, a final solution osmolality up to 6000mOsmo/kg is contemplated. Unexpectantly, formulations described hereindemonstrate good tolerability at high osmolalities.

In another embodiment, a pharmaceutical composition of liquidpirfenidone or pyridone analog may contain a solubility enhancing agentor co-solvent. By non-limiting example, these may include ethanol,cetylpridinium chloride, glycerin, lecithin, propylene glycol,polysorbate (including polysorbate 20, 40, 60, 80 and 85), sorbitantriolate, and the like. By further example, cetylpridinium chloride maybe used from about 0.01 mg/mL to about 4 mg/mL pharmaceuticalcomposition. Similarly, by another non-limiting example, ethanol may beused from about 0.01% to about 30% pharmaceutical composition.Similarly, by another non-limiting example, glycerin may be used fromabout 0.01% to about 25% pharmaceutical composition. Similarly, byanother non-limiting example, lecithin may be used from about 0.01% toabout 4% pharmaceutical composition. Similarly, by another non-limitingexample, propylene glycol may be used from about 0.01% to about 30%pharmaceutical composition. Similarly, by another non-limiting example,polysorbates may also be used from about 0.01% to about 10%pharmaceutical composition. Similarly, by another non-limiting example,sorbitan triolate may be used from about 0.01% to about 20%pharmaceutical composition.

In another embodiment, a pharmaceutical composition of liquid or drypowder pirfenidone or pyridone analog may contain a chelated metal ionto assist in solubility and/or dissolution of pirfenidone or pyridoneanalog. By non-limiting example, these may include iron, magnesium, orcalcium.

In another embodiment, a pharmaceutical composition of liquid or drypowder pirfenidone or pyridone analog may contain a chelated metal ionto assist in scavenging reactive oxygen species. By non-limitingexample, these may include iron, magnesium, or calcium. By non-limitingexample, for this purpose the addition of magnesium or other cationicmetal ion may be stoichiometric to the amount of pirfenidone or pyridoneanalog. By non-limiting example, 2 pirfenidone molecules to 0.1magnesium molecules, 2 pirfenidone molecules to 0.25 magnesiummolecules, 2 pirfenidone molecules to 0.5 magnesium molecules, 2pirfenidone molecules to 0.75 magnesium molecules, 2 pirfenidonemolecules to 1 magnesium molecules, 2 pirfenidone molecules to 1.5magnesium molecules, 2 pirfenidone molecules to 2 magnesium molecules, 2pirfenidone molecules to 3 magnesium molecules, 2 pirfenidone moleculesto 4 magnesium molecules, 2 pirfenidone molecules to 5 magnesiummolecules, 2 pirfenidone molecules to 6 magnesium molecules, 2pirfenidone molecules to 7 magnesium molecules, 2 pirfenidone moleculesto 8 magnesium molecules, 2 pirfenidone molecules to 9 magnesiummolecules, 2 pirfenidone molecules to 10 magnesium molecules, 2pirfenidone molecules to 12 magnesium molecules, 2 pirfenidone moleculesto 14 magnesium molecules, 2 pirfenidone molecules to 16 magnesiummolecules, 2 pirfenidone molecules to 18 magnesium molecules, or 2pirfenidone molecules to 20 magnesium molecules. Potassium, sodium,lithium or iron may substitute for magnesium in these ratios andpharmaceutical composition. Included in the above pharmaceuticalcomposition is the maintenance of the buffers described herein, at a pHfrom about 4.0 to about 8.0, and include MgCl₂ or cationic salt thereofat a level that provides an osmolality of 300 mOsmo/kg and 600 mOsmo/kg.While 300 mOsmo/kg is discussed in the literature as important for acutetolerability upon inhalation of this in a nebulized solution, 600mOsmo/kg has been shown in unpublished studies to be well tolerated withother drug solutions. However, a final solution osmolality up to 5000mOsmo/kg is contemplated.

In some embodiments, described herein is a pharmaceutical compositionthat includes: pirfenidone; water; phosphate buffer or citrate buffer;and optionally sodium chloride or magnesium chloride. In otherembodiments, described herein is a pharmaceutical composition thatincludes: pirfenidone; water; a buffer; and at least one additionalingredient selected from sodium chloride, magnesium chloride, ethanol,propylene glycol, glycerol, polysorbate 80, and cetylpyridinium bromide(or chloride). In some embodiments, the buffer is phosphate buffer. Inother embodiments, the buffer is citrate buffer. In some embodiments,the pharmaceutical composition includes 1 mg to 500 mg of pirfenidone,for example, 5 mg, 10 mg, 15 mg, 25 mg, 37.5 mg, 75 mg, 100 mg, 115 mg,150 mg, 190 mg, 220 mg, or 500 mg. In some embodiments, the osmolalityof the pharmaceutical composition described herein is between about 50mOsmo/kg to 6000 mOsmo/kg. In some embodiments, the pharmaceuticalcomposition optionally includes saccharin (e.g. sodium salt).Non-limiting examples of pharmaceutical compositions described hereininclude any one of the pharmaceutical compositions described in Tables1-1 to Table 1-11 of Example 1.

Solutions of pirfenidone should remain protected from light as the APIin solution is subject to degradation

In another embodiment, a pharmaceutical composition is provided thatincludes a simple dry powder pirfenidone or pyridone analog (or saltthereof) compound alone in dry powder form with or without a blendingagent such as lactose.

In another embodiment, the pharmaceutical composition used in a liquid,dry powder or meter-dose inhalation device is provided such thatpirfenidone or pyridone analog is not in a salt form.

In another embodiment, a pharmaceutical composition is provided thatincludes a complex dry powder pirfenidone or pyridone analog (or saltthereof) compound formulation in co-crystal/co-precipitate/spray driedcomplex or mixture with low water soluble excipients/salts in dry powderform with or without a blending agent such as lactose.

In another embodiment, a system is provided for administering apirfenidone or pyridone analog (or salt thereof) compound that includesa container comprising a solution of a pirfenidone or pyridone analog(or salt thereof) compound formulation and a nebulizer physicallycoupled or co-packaged with the container and adapted to produce anaerosol of the solution having a particle size from about 1 microns toabout 5 microns mean mass aerodynamic diameter, volumetric mean diameter(VMD) or mass median diameter (MMD) and a particle size geometricstandard deviation of less than or equal to about 2.5 microns mean massaerodynamic diameter. In one embodiment, the particle size geometricstandard deviation is less than or equal to about 3.0 microns. In oneembodiment, the particle size geometric standard deviation is less thanor equal to about 2.0 microns.

In another embodiment, a system is provided for administering apirfenidone or pyridone analog (or salt thereof) compound that includesa container comprising a dry powder of a pirfenidone or pyridone analog(or salt thereof) compound and a dry powder inhaler coupled to thecontainer and adapted to produce a dispersed dry powder aerosol having aparticle size from about 1 microns to about 5 microns mean massaerodynamic and a particle size standard deviation of less than or equalto about 3.0 microns. In one embodiment, the particle size standarddeviation is less than or equal to about 2.5 microns. In one embodiment,the particle size standard deviation is less than or equal to about 2.0microns.

In another embodiment, a kit is provided that includes a containercomprising a pharmaceutical formulation comprising a pirfenidone orpyridone analog (or salt thereof) compound and an aerosolizer adapted toaerosolize the pharmaceutical formulation (e.g., in certain preferredembodiments, a liquid nebulizer) and deliver it to the lower respiratorytract, for instance, to a pulmonary compartment such as alveoli,alveolar ducts and/or bronchioles, following intraoral administration.The formulation may also be delivered as a dry powder or through ametered-dose inhaler.

In another embodiment, a kit is provided that includes a containercomprising a pharmaceutical formulation comprising a pirfenidone orpyridone analog (or salt thereof) compound and an aerosolizer adapted toaerosolize the pharmaceutical formulation (e.g., in certain preferredembodiments, a liquid nebulizer) and deliver it to a nasal cavityfollowing intranasal administration. The formulation may also bedelivered as a dry powder or through a metered-dose inhaler.

It should be understood that many carriers and excipients may serveseveral functions, even within the same formulation.

Contemplated pharmaceutical compositions provide a therapeuticallyeffective amount of pirfendione or pyridone analog compound enabling,for example, once-a-day, twice-a-day, three times a day, etc.administration. In some embodiments, pharmaceutical compositions forinhaled delivery provide an effective amount of pirfendione or pyridoneanalog compound enabling once-a-day dosing. In some embodiments,pharmaceutical compositions for inhaled delivery provide an effectiveamount of pirfendione or pyridone analog compound enabling twice-a-daydosing. In some embodiments, pharmaceutical compositions for inhaleddelivery provide an effective amount of pirfendione or pyridone analogcompound enabling three times-a-day dosing.

It is to be understood that both the foregoing general description andthe following detailed description are exemplary and explanatory onlyand are not restrictive of the invention, as claimed.

Certain Terminology

The term “mg” refers to milligram.

The term “mcg” refers to microgram.

The term “microM” refers to micromolar.

The term “QD” refers to once a day dosing.

The term “BID” refers to twice a day dosing.

The term “TID” refers to three times a day dosing.

The term “QID” refers to four times a day dosing.

As used herein, the term “about” is used synonymously with the term“approximately.” Illustratively, the use of the term “about” with regardto a certain therapeutically effective pharmaceutical dose indicatesthat values slightly outside the cited values, e.g., plus or minus 0.1%to 10%, which are also effective and safe.

As used herein, the terms “comprising,” “including,” “such as,” and “forexample” are used in their open, non-limiting sense.

The terms “administration” or “administering” and “delivery” or“delivery” refer to a method of giving to a mammal a dosage of atherapeutic or prophylactic formulation, such as a pirfenidone orpyridone analog (or salt thereof) compound formulation described herein,for example as an anti-inflammatory, anti-fibrotic and/oranti-demylination pharmaceutical composition, or for other purposes. Thepreferred delivery method or method of administration can vary dependingon various factors, e.g., the components of the pharmaceuticalcomposition, the desired site at which the formulation is to beintroduced, delivered or administered, the site where therapeuticbenefit is sought, or the proximity of the initial delivery site to thedownstream diseased organ (e.g., aerosol delivery to the lung forabsorption and secondary delivery to the heart, kidney, liver, centralnervous system or other diseased destination). In some embodiments,pharmaceutical compositions described herein are administered bypulmonary administration.

The terms “pulmonary administration” or “inhalation” or “pulmonarydelivery” or “oral inhalation” or “intranasal inhalation” and otherrelated terms refer to a method of giving to a mammal a dosage of atherapeutic or prophylactic formulation, such as a pirfenidone orpyridone analog (or salt thereof) compound formulation described herein,by a route such that the desired therapeutic or prophylactic agent isdelivered to the lungs of a mammal. Such delivery to the lung may occurby intranasal administration, oral inhalation administration. Each ofthese routes of administration may occur as inhalation of an aerosol offormulations described herein. In some embodiments, pulmonaryadministration occurs by passively delivering an aerosol describedherein by mechanical ventilation.

The terms “intranasal inhalation administration” and “intranasalinhalation delivery” refer to a method of giving to a mammal a dosage ofa pirfenidone or pyridone analog (or salt thereof) compound formulationdescribed herein, by a route such that the formulation is targetingdelivery and absorption of the therapeutic formulation directly in thelungs of the mammal through the nasal cavity. In some embodiments,intranasal inhalation administration is performed with a nebulizer.

The terms “intranasal administration” and “intranasal delivery” refer toa method of giving to a mammal a dosage of a therapeutic or prophylacticformulation, such as a pirfenidone or pyridone analog (or salt thereof)compound formulation described herein, by a route such that the desiredtherapeutic or prophylactic agent is delivered to the nasal cavity ordiseased organs downstream (e.g., aerosol delivery to the nasal cavityfor absorption and secondary delivery to the central nervous system orother diseased destination). Such delivery to the nasal cavity may occurby intranasal administration, wherein this route of administration mayoccur as inhalation of an aerosol of formulations described herein,injection of an aerosol of formulations described herein, gavage of aformulation described herein, or passively delivered by mechanicalventilation.

The terms “intraoccular administration” and “intraoccular delivery”refer to a method of giving to a mammal a dosage of a therapeutic orprophylactic formulation, such as a pirfenidone or pyridone analog (orsalt thereof) compound formulation described herein, by a route suchthat the desired therapeutic or prophylactic agent is delivered to theeye. Such delivery to the eye may occur by direct administration to theeye. This route of administration may occur as spray of an aerosol offormulations described herein, injection of an aerosol of formulationsdescribed herein, or drops of a formulation described herein.

“Oral administration” or “orally” or “oral” is a route of administrationwhere a substance (e.g. a pharmaceutical composition) is taken throughthe mouth. In some embodiments, when it is used without any furtherdescriptors, it refers to administration of a substance through themouth and directly into the gastrointestinal tract. Oral administrationgenerally includes a number of forms, such as tablets, pills, capsules,and solutions.

The terms “oral inhalation administration” or “oral inhalation delivery”or “oral inhalation” refer to a method of giving to a mammal a dosage ofa pirfenidone or pyridone analog (or salt thereof) compound formulationdescribed herein, through the mouth for delivery and absorption of theformulation directly to the lungs of the mammal. In some embodiments,oral inhalation administration is carried out by the use of a nebulizer.

The term “abnormal liver function” may manifest as abnormalities inlevels of biomarkers of liver function, including alanine transaminase,aspartate transaminase, bilirubin, and/or alkaline phosphatase, and maybe an indicator of drug-induced liver injury. See FDA Draft Guidance forIndustry. Drug-Induced Liver Injury: Premarketing Clinical Evaluation,October 2007.

“Grade 2 liver function abnormalities” include elevations in alaninetransaminase (ALT), aspartate transaminase (AST), alkaline phosphatase(ALP), or gamma-glutamyl transferase (GGT) greater than 2.5-times andless than or equal to 5-times the upper limit of normal (ULN). Grade 2liver function abnormalities also include elevations of bilirubin levelsgreater than 1.5-times and less than or equal to 3-times the ULN.

“Gastrointestinal adverse events” include but are not limited to any oneor more of the following: dyspepsia, nausea, diarrhea, gastroesophagealreflux disease (GERD) and vomiting.

A “carrier” or “excipient” is a compound or material used to facilitateadministration of the compound, for example, to increase the solubilityof the compound. Solid carriers include, e.g., starch, lactose,dicalcium phosphate, sucrose, and kaolin. Liquid carriers include, e.g.,sterile water, saline, buffers, non-ionic surfactants, and edible oilssuch as oil, peanut and sesame oils. In addition, various adjuvants suchas are commonly used in the art may be included. These and other suchcompounds are described in the literature, e.g., in the Merck Index,Merck & Company, Rahway, N.J. Considerations for the inclusion ofvarious components in pharmaceutical compositions are described, e.g.,in Gilman et al. (Eds.) (1990); Goodman and Gilman's: ThePharmacological Basis of Therapeutics, 8th Ed., Pergamon Press.

A “diagnostic” as used herein is a compound, method, system, or devicethat assists in the identification and characterization of a health ordisease state. The diagnostic can be used in standard assays as is knownin the art.

“Patient” or “subject” are used interchangeably and refer to a mammal.

The term “mammal” is used in its usual biological sense. In someembodiments, a mammal is a human.

The term “ex vivo” refers to experimentation or manipulation done in oron living tissue in an artificial environment outside the organism.

The term “pharmaceutically acceptable carrier” or “pharmaceuticallyacceptable excipient” includes any and all solvents, dispersion media,coatings, antibacterial and antifungal agents, isotonic and absorptiondelaying agents and the like. The use of such media and agents forpharmaceutically active substances is well known in the art. Exceptinsofar as any conventional media or agent is incompatible with theactive ingredient, its use in the therapeutic compositions iscontemplated. Supplementary active ingredients can also be incorporatedinto the compositions.

The term “pharmaceutically acceptable salt” refers to salts that retainthe biological effectiveness and properties of the compounds of thisinvention and, which are not biologically or otherwise undesirable. Inmany cases, the compounds of this invention are capable of forming acidand/or base salts by virtue of the presence of amino and/or carboxylgroups or groups similar thereto. Pharmaceutically acceptable acidaddition salts can be formed with inorganic acids and organic acids.Inorganic acids from which salts can be derived include, for example,hydrochloric acid, hydrobromic acid, sulfuric acid, nitric acid,phosphoric acid, and the like. Organic acids from which salts can bederived include, for example, acetic acid, propionic acid, naphtoicacid, oleic acid, palmitic acid, pamoic (emboic) acid, stearic acid,glycolic acid, pyruvic acid, oxalic acid, maleic acid, malonic acid,succinic acid, fumaric acid, tartaric acid, citric acid, ascorbic acid,glucoheptonic acid, glucuronic acid, lactic acid, lactobioic acid,tartaric acid, benzoic acid, cinnamic acid, mandelic acid,methanesulfonic acid, ethanesulfonic acid, p-toluenesulfonic acid,salicylic acid, and the like. Pharmaceutically acceptable base additionsalts can be formed with inorganic and organic bases. Inorganic basesfrom which salts can be derived include, for example, sodium, potassium,lithium, ammonium, calcium, magnesium, iron, zinc, copper, manganese,aluminum, and the like; particularly preferred are the ammonium,potassium, sodium, calcium and magnesium salts. Organic bases from whichsalts can be derived include, for example, primary, secondary, andtertiary amines, substituted amines including naturally occurringsubstituted amines, cyclic amines, basic ion exchange resins, and thelike, specifically such as isopropylamine, trimethylamine, diethylamine,triethylamine, tripropylamine, histidine, arginine, lysine, benethamine,N-methyl-glucamine, and ethanolamine. Other acids include dodecylsufuricacid, naphthalene-1,5-disulfonic acid, naphthalene-2-sulfonic acid, andsaccharin.

The term “pH-reducing acid” refers to acids that retain the biologicaleffectiveness and properties of the compounds of this invention and,which are not biologically or otherwise undesirable. Pharmaceuticallyacceptable pH-reducing acids include, for example, inorganic acids suchas, e.g., hydrochloric acid, hydrobromic acid, sulfuric acid, nitricacid, phosphoric acid, and the like. Also by nonlimiting example,pH-reducing acids may also include organic acids such as citric acid,acetic acid, propionic acid, naphtoic acid, oleic acid, palmitic acid,pamoic (emboic) acid, stearic acid, glycolic acid, pyruvic acid, oxalicacid, maleic acid, malonic acid, succinic acid, fumaric acid, tartaricacid, citric acid, ascorbic acid, glucoheptonic acid, glucuronic acid,lactic acid, lactobioic acid, tartaric acid, benzoic acid, cinnamicacid, mandelic acid, methanesulfonic acid, ethanesulfonic acid,p-toluenesulfonic acid, salicylic acid, and the like.

According to certain herein disclosed embodiments a pirfenidone or apyridone analog compound formulation may comprise an “acidic excipient”that is typically present as an acidic excipient aqueous solution.Examples of may include acid salts such as phosphate, sulphate, nitrate,acetate, formate, citrate, tartrate, propionate and sorbate, organicacids such as carboxylic acids, sulfonic acids, phosphonic acids,phosphinic acids, phosphoric monoesters, and phosphoric diesters, and/orother organic acids that contain from 1 to 12 carbon atoms, citric acid,acetic acid, formic acid, propionic acid, butyric acid, benzoic acid,mono-, di-, and trichloroacetic acid, salicylic acid, trifluoroaceticacid, benzenesulfonic acid, toluenesulfonic acid, methylphosphonic acid,methylphosphinic acid, dimethylphosphinic acid, and phosphonic acidmonobutyl ester.

A “buffer” refers to a compound that functions to regulate pH. Incertain related embodiments the pH buffer is present under conditionsand in sufficient quantity to maintain a pH that is “about” a recited pHvalue. “About” such a pH refers to the functional presence of thatbuffer, which, as is known in the art, may be a consequence of a varietyof factors including pKa value(s) of the buffer, buffer concentration,working temperature, effects of other components of the composition onpKa (i.e., the pH at which the buffer is at equilibrium betweenprotonated and deprotonated forms, typically the center of the effectivebuffering range of pH values), and other factors.

Hence, “about” in the context of pH may be understood to represent aquantitative variation in pH that may be more or less than the recitedvalue by no more than 0.5 pH units, more preferably no more than 0.4 pHunits, more preferably no more than 0.3 pH units, still more preferablyno more than 0.2 pH units, and most preferably no more than 0.1-0.15 pHunits. As also noted above, in certain embodiments a substantiallyconstant pH (e.g., a pH that is maintained within the recited range foran extended time period) may be from about pH 4.0 to about pH 8.0, fromabout pH 4.0 to about pH 7.0, or from about pH 4.0 to about pH 6.8, orany other pH or pH range as described herein, which in preferredembodiments may be from about pH 4.0 to about pH 8.0 for a pirfenidoneor pyridone analog compound formulation, and greater than about pH 8.0for a pirfenidone or pyridone analog compound aqueous solution.

Therefore the pH buffer typically may comprise a composition that, whenpresent under appropriate conditions and in sufficient quantity, iscapable of maintaining a desired pH level as may be selected by thosefamiliar with the art, for example, buffers comprising citrate, formate,malate, formate, pyridine, piperazine, succinate, histidine, maleate,bis-Tris, pyrophosphate, PIPES, ACES, histidine, MES, cacodylic acid,H2CO3/NaHCO₃ and N-(2-Acetamido)-2-iminodiacetic acid (ADA) or otherbuffers for maintaining, preserving, enhancing, protecting or otherwisepromoting desired biological or pharmacological activity of apirfenidone or pyridone analog compound, based on the disclosure herein.Suitable buffers may include those in Table 1 or known to the art (see,e.g., Calbiochem® Biochemicals & Immunochemicals Catalog 2004/2005, pp.68-69 and catalog pages cited therein, EMD Biosciences, La Jolla,Calif.).

Non-limiting examples of buffers that may be used according to certainembodiments disclosed herein, include but are not limited to formate(pKa 3.77), Citric acid (pKa2 4.76), Malate (pKa2 5.13), Pyridine (pKa5.23), Piperazine ((pKa1) 5.33), Succinate ((pKa2) 5.64), Histidine (pKa6.04), Maleate ((pKa2) 6.24), Citric acid ((pKa3) 6.40), Bis-Tris (pKa6.46), Pyrophosphate ((pKa3) 6.70), PIPES (pKa 6.76), ACES (pKa 6.78),Histidine (pKa 6.80), MES (pKa 6.15), Cacodylic acid (pKa 6.27),H2CO3/NaHCO3 (pKa1) (6.37), ADA (N-(2-Acetamido)-2-iminodiacetic acid)(pKa 6.60). In some embodiments, pharmaceutical compositions disclosedherein include a citrate buffer or a phosphate buffer. In someembodiments, pharmaceutical compositions disclosed herein include acitrate buffer. In some embodiments, pharmaceutical compositionsdisclosed herein include a phosphate buffer.

“Solvate” refers to the compound formed by the interaction of a solventand pirfenidone or a pyridone analog compound, a metabolite, or saltthereof. Suitable solvates are pharmaceutically acceptable solvatesincluding hydrates.

By “therapeutically effective amount” or “pharmaceutically effectiveamount” is meant pirfenidone or a pyridone analog compound, as disclosedfor this invention, which has a therapeutic effect. The doses ofpirfenidone or a pyridone analog compound which are useful in treatmentare therapeutically effective amounts. Thus, as used herein, atherapeutically effective amount means those amounts of pirfenidone or apyridone analog compound which produce the desired therapeutic effect asjudged by clinical trial results and/or model animal pulmonary fibrosis,cardiac fibrosis, kidney fibrosis, hepatic fibrosis, heart or kidneytoxicity, multiple sclerosis, COPD or asthma. In particular embodiments,the pirfenidone or pyridone analog compounds are administered in apre-determined dose, and thus a therapeutically effective amount wouldbe an amount of the dose administered. This amount and the amount of thepirfenidone or pyridone analog compound can be routinely determined byone of skill in the art, and will vary, depending on several factors,such as the therapeutic or prophylactic effect for fibrotic,inflammatory or demylination injury occurs, and how distant that diseasesite is from the initial respiratory location receiving the initialinhaled aerosol dose. This amount can further depend upon the patient'sheight, weight, sex, age and medical history. For prophylactictreatments, a therapeutically effective amount is that amount whichwould be effective to prevent a fibrotic, inflammatory or demylinationinjury.

A “therapeutic effect” relieves, to some extent, one or more of thesymptoms associated with inflammation, fibrosis and/or demylination.This includes slowing the progression of, or preventing or reducingadditional inflammation, fibrosis and/or demylination. For IPF, a“therapeutic effect” is defined as a patient-reported improvement inquality of life and/or a statistically significant increase in orstabilization of exercise tolerance and associated blood-oxygensaturation, reduced decline in baseline forced vital capacity, decreasedincidence in acute exacerbations, increase in progression-free survival,increased time-to-death or disease progression, and/or reduced lungfibrosis. For cardiac fibrosis, a “therapeutic effect” is defined as apatient-reported improvement in quality of life and/or a statisticallysignificant improvement in cardiac function, reduced fibrosis, reducedcardiac stiffness, reduced or reversed valvular stenosis, reducedincidence of arrhythmias and/or reduced atrial or ventricularremodeling. For kidney fibrosis, a “therapeutic effect” is defined as apatient-reported improvement in quality of life and/or a statisticallysignificant improvement in glomular filtration rate and associatedmarkers. For hepatic fibrosis, a “therapeutic effect” is defined as apatient-reported improvement in quality of life and/or a statisticallysignificant lowering of elevated aminotransferases (e.g., AST and ALT),alkaline phosphatases, gamma-glutamyl transferase, bilirubin,prothrombin time, globulins, as well as reversal of thromobocytopenia,leukopenai and neutropenia and coagulation defects. Further a potentialreversal of imaging, endoscopic or other pathological findings. ForCOPD, a “therapeutic effect” is defined as a patient-reportedimprovement in quality of life and/or a statistically significantimproved exercise capacity and associated blood-oxygen saturation, FEV1and/or FVC, a slowed or halted progression in the same, progression-freesurvival, increased time-to-death or disease progression, and/or reducedincidence or acute exacerbation. For asthma, a “therapeutic effect” isdefined as a patient-reported improvement in quality of life and/or astatistically significantly improved exercise capacity, improved FEV1and/or FVC, and/or reduced incidence or acute exacerbation. For multiplesclerosis, a “therapeutic effect” is defined as a patient-reportedimprovement in quality of life and/or a statistically significantlyimproved Scripps Neurological Rating Scale score, improvement in bladderdysfunction, improved Disability Status Socres, MRI lesion count, and/oran slowed or halted progression of disease.

“Treat,” “treatment,” or “treating,” as used herein refers toadministering a pharmaceutical composition for therapeutic purposes. Insome embodiments, treating refers to alleviating, abating orameliorating at least one symptom of a disease or condition, preventingany additional symptoms from arising, arresting the progression of atleast one current symptom of the disease or condition, relieving atleast one of the symptoms of a disease or condition, causing regressionof the disease or condition, relieving a condition caused by the diseaseor condition, or stopping the symptoms of the disease or condition. Insome embodiments, the compositions described herein are used forprophylactic treatment. The term “prophylactic treatment” refers totreating a patient who is not yet diseased but who is susceptible to, orotherwise at risk of, a particular disease, or who is diseased but whosecondition does not worsen while being treated with the pharmaceuticalcompositions described herein. The term “therapeutic treatment” refersto administering treatment to a patient already suffering from adisease. Thus, in preferred embodiments, treating is the administrationto a mammal (either for therapeutic or prophylactic purposes) oftherapeutically effective amounts of pirfenidone or a pyridone analogcompound.

“Treat,” “treatment,” or “treating,” as used herein refers toadministering a pharmaceutical composition for prophylactic and/ortherapeutic purposes. The term “prophylactic treatment” refers totreating a patient who is not yet diseased, but who is susceptible to,or otherwise at risk of, a particular disease. The term “therapeutictreatment” refers to administering treatment to a patient alreadysuffering from a disease. Thus, in preferred embodiments, treating isthe administration to a mammal (either for therapeutic or prophylacticpurposes) of therapeutically effective amounts of pirfenidone or apyridone analog compound.

The term “dosing interval” refers to the time between administrations ofthe two sequential doses of a pharmaceutical's during multiple dosingregimens.

The “respirable delivered dose” is the amount of aerosolized pirfenidoneor a pyridone analog compound particles inhaled during the inspiratoryphase of the breath simulator that is equal to or less than 5 microns.

“Lung Deposition” as used herein, refers to the fraction of the nominaldose of an active pharmaceutical ingredient (API) that is deposited onthe inner surface of the lungs.

“Nominal dose,” or “loaded dose” refers to the amount of drug that isplaced in the nebulizer prior to administration to a mammal. The volumeof solution containing the nominal dose is referred to as the “fillvolume.”

“Enhanced pharmacokinetic profile” means an improvement in somepharmacokinetic parameter. Pharmacokinetic parameters that may beimproved include, AUClast, AUC(0-∞) Tmax, and optionally a Cmax. In someembodiments, the enhanced pharmacokinetic profile may be measuredquantitatively by comparing a pharmacokinetic parameter obtained for anominal dose of an active pharmaceutical ingredient (API) administeredwith one type of inhalation device with the same pharmacokineticparameter obtained with oral administration of a composition of the sameactive pharmaceutical ingredient (API).

“Blood plasma concentration” refers to the concentration of an activepharmaceutical ingredient (API) in the plasma component of blood of asubject or patient population.

“Respiratory condition,” as used herein, refers to a disease orcondition that is physically manifested in the respiratory tract,including, but not limited to, pulmonary fibrosis, chronic obstructivepulmonary disease (COPD), bronchitis, chronic bronchitis, emphysema, orasthma.

“Nebulizer,” as used herein, refers to a device that turns medications,compositions, formulations, suspensions, and mixtures, etc. into a finemist or aerosol for delivery to the lungs. Nebulizers may also bereferred to as atomizers.

“Drug absorption” or simply “absorption” typically refers to the processof movement of drug from site of delivery of a drug across a barrierinto a blood vessel or the site of action, e.g., a drug being absorbedin the pulmonary capillary beds of the alveoli.

Pirfenidone and Pyridone Analog Compounds

As also noted elsewhere herein, in preferred embodiments the pyridonecompound for use in a pyridone compound formulation as described hereincomprises pirfenidone (5-methyl-1-phenyl-2-(1H)-pyridone) or a saltthereof. Although various embodiments are described with the use ofpirfenidone, it is noted that other pyridone analog compounds, or saltsthereof, may be used in place of pirfenidone.

Pirfenidone is also known as 5-methyl-1-phenyl-2-(1H)-pyridone and hasthe structure:

“Pyridone analog” or “pyridone compound” refers to compounds that havethe same type of biological activity and effectiveness as pirfenidone.Such pyridone analog compounds are those that upon administration to amammal produce anti-inflammatory, anti-fibrotic and/or anti-demylinationactivity for therapeutic or prophylactic purposes. In some embodiments,a pyridone analog is a compound that has a substituted 2-(1H)pyridone or3-(1H)pyridone core structure. In some embodiments, a pyridone analog isa compound that has a substituted 2-(1H)pyridone core structure.

1-Phenyl-2-(1H)pyridone, 5-methyl-1-(4-methylphenyl)-2-(1H)-pyridone,5-methyl-1-(4-hydroxyphenyl)-2-(1H)-pyridone,5-methyl-1-(4-methoxyphenyl)-2-(1H)-pyridone,5-Methyl-1-(2′-pyridyl)-2-(1H)pyridone,6-Methyl-1-phenyl-3-(1H)pyridone, 6-Methyl-1-phenyl-2-(1H)pyridone,5-Methyl-1-p-tolyl-3-(1H)pyridone,5-Methyl-3-phenyl-1-(2′-thienyl)-2-(1H)pyridone,5-Methyl-1-(2′-naphthyl)-3-(1H)pyridone,5-Methyl-1-(2′-naphthyl)-2-(1H)pyridone,5-Methyl-1-phenyl-3-(1H)pyridone, 5-Methyl-1-p-tolyl-2-(1H)pyridone,5-Methyl-1-(1′naphthyl)-2-(1H)pyridone,5-Methyl-1-(5′-quinolyl)-3-(1H)pyridone,5-Ethyl-1-phenyl-2-(1H)pyridone, 5-Ethyl-1-phenyl-3-(1H)pyridone,5-Methyl-1-(5′-quinolyl)-2-(1H)pyridone,5-Methyl-1-(4′-methoxyphenyl)-3-(1H)pyridone,5-Methyl-1-(4′-quinolyl)-2-(1H)pyridone,4-Methyl-1-phenyl-3-(1H)pyridone,5-Methyl-1-(4′-pyridyl)-2-(1H)pyridone,5-Methyl-1-(3′-pyridyl)-3-(1H)pyridone,3-Methyl-1-phenyl-2-(1H)pyridone,5-Methyl-1-(4′-methoxyphenyl)-2-(1H)pyridone,5-Methyl-1-(2′-Thienyl)-3-(1H)pyridone,5-Methyl-1-(2′-pyridyl)-3-(1H)pyridone, 1,3-Diphenyl-2-(1H)pyridone,1,3-Diphenyl-5-methyl-2-(1H)pyridone,5-Methyl-1-(2′-quinolyl)-3-(1H)pyridone,5-Methyl-1-(3′-trifluoromethylphenyl)-2-(1H)pyridone,1-Phenyl-3-(1H)pyridone, 1-(2′-Furyl)-5-methyl-3-(1H)-pyridone,3-Ethyl-1-phenyl-2-(1H)pyridone,1-(4′-Chlorophenyl)-5-methyl-(1H)pyridone,5-Methyl-1-(3′-pyridyl)-2-3-(1H)pyridone,5-Methyl-1-(3-nitrophenyl)-2-(1H)pyridone,3-(4′-Chlorophenyl)-5-Methyl-1-phenyl-2-(1H)pyridone,5-Methyl-1-(2′-Thienyl)-2-(1H)pyridone,5-Methyl-1-(2′-thiazolyl)-2-(1H)pyridone,3,6-Dimethyl-1-phenyl-2-(1H)pyridone,1-(4′Chlorophenyl)-5-Methyl-2-(1H)pyridone,1-(2′-Imidazolyl)-5-Methyl-2-(1H)pyridone,1-(4′-Nitrophenyl)-2-(1H)pyridone, 1-(2′-Furyl)-5-Methyl-2-(1H)pyridone,1-Phenyl-3-(4′-chlorophenyl)-2-(1H)pyridone.

In some embodiments, a pyridone analog compound is a compound describedin US patent publication no. US20090005424; US patent publication no.20070092488; U.S. Pat. No. 8,022,087; U.S. Pat. No. 6,090,822; U.S. Pat.No. 5,716,632; U.S. Pat. No. 5,518,729; U.S. Pat. No. 5,310,562; U.S.Pat. No. 4,052,509; U.S. Pat. No. 4,042,699; U.S. Pat. No. 3,839,346; orU.S. Pat. No. 3,974,281; each of which is herein incorporated byreference for such compounds.

In some embodiments, a pyridone analog compound is a compound describedin US patent publication no. US20140107110; US patent publication no.20140094456; or WO/2014/055548; each of which is herein incorporated byreference for such compounds.

In some embodiments, a pyridone analog compound is ITMN-30162, or apharmaceutically acceptable salt thereof.

In some embodiments, a pyridone analog is a deuterated pirfenidonecompound, where 1 or more hydrogen atoms of pirfenidone are replacedwith deuterium.

According to certain other distinct embodiments of the compositions andmethods described herein, the pyridone compound is selected from thegroup consisting of bis(2-hydroxyethyl)azanium;2-(3,5-diiodo-4-oxopyridin-1-yl)acetate, propyl2-(3,5-diiodo-4-oxopyridin-1-yl)acetate,2-[3-[4-(3-chlorophenyl)piperazin-1-yl]propyl][1,2,4]triazolo[4,3-a]pyridin-3-one hydrochloride,2-[3-[4-(3-chlorophenyl)piperazin-1-yl]propyl]-[1,2,4]triazolo[4,3-a]pyridin-3-one,3-anilino-1-phenylpropan-1-one,2-[3-[4-(3-chlorophenyl)piperazin-1-yl]propyl]-[1,2,4]triazolo[4,3-a]pyridin-3-onehydrochloride,2-[3-[4-(3-chlorophenyl)piperazin-1-yl]propyl]-[1,2,4]triazolo[4,3a]pyridin-3-one, 2S)-2-amino-3-(3-hydroxy-4-oxopyridin-1-yl)propanoicacid, 2-[3-[4(3-chlorophenyl)piperazin-1-yl]propyl]-[1,2,4]triazolo[4,3-a]pyridin-3-one,2-[3-[4-(3-chlorophenyl)piperazin-1-yl]propyl]-[1,2,4]triazolo[4,3-a]pyridin-3-onehydrochloride,2-[3-[4-(3-chlorophenyl)piperazin-1-yl]propyl]-[1,2,4]triazolo[4,3-a]pyridin-3-onehydrochloride, (2S)-2-[(3-hydroxy-4-oxopyridin-1-yl)amino] propanoicacid, 2-[3-[4-(3chlorophenyl)piperazin-1-yl]propyl]-[1,2,4]triazolo[4,3-a]pyridin-3-onehydrochloride, 2-amino-3-(3-hydroxy-4-oxopyridin-1-yl)propanoic acid,2-[3-[4-(3chlorophenyl)piperazin-1-yl]propyl]-[1,2,4]triazolo[4,3-a]pyridin-3-onehydrochloride, propyl 2-(3,5-diiodo-4-oxopyridin-1-yl)acetate,2-(3,5-diiodo-4-oxopyridin-1-yl)acetic acid; 2-(2hydroxyethylamino)ethanol,(2S)-2-amino-3-(3-hydroxy-4-oxopyridin-1-yl)propanoic acid,(2R)-2-amino-3-(3-hydroxy-4-oxopyridin-1-yl)propanoic acid,2-amino-3-(3-hydroxy-4-oxopyridin-1-yl)propanoic acid,5-cyano-6-methyl-N-[4(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,6-methyl-N-[4-(methylsulfonyl)benzyl]-5-nitro-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(1-butoxyvinyl)-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-acetyl-6-methyl-N-[4-(methyl sulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-[(1E)-N-methoxyethanimidoyl]-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-[(1E)-N-hydroxyethanimidoyl]-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-5-(pyridin-3-ylethynyl)-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-5-(2-pyridin-3-ylethyl)-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-5-vinyl-1,2-dihydropyridine-3-carboxamide,ethyl 2-methyl-5-({[4(methylsulfonyl)benzyl]amino}carbonyl)-6-oxo-1-[3-(trifluoromethyl)phenyl]-1,6-dihydropyridine-3-carboxylate,5-(4-methanesulfonyl-benzylcarbamoyl)-2-methyl-6-oxo-1-(3-trifluoromethyl-phenyl)-1,6-dihydro-pyridine-3-carboxylicacid,6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3,5-dicarboxylicacid 5-dimethylamide 3-(4-methanesulfonyl-benzylamide),6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3,5-dicarboxylicacid 5-amide 3-(4-methanesulfonyl-benzylamide),6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3,5-dicarboxylicacid 3-(4-methanesulfonyl-benzylamide)5-methylamide,6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3,5-dicarboxylicacid5-[(2-hydroxy-ethyl)-methyl-amide]3-(4-methanesulfonyl-benzylamide),6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3,5-dicarboxylicacid 3-(4-methanesulfonyl-benzylamide)5-(methyl-propyl-amide),6-methyl-2-oxo-5-(pyrrolidine-1-carbonyl)-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3,5-dicarboxylicacid 3-(4-methanesulfonyl-benzylamide),6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3,5-dicarboxylicacid5-[(2-dimethylamino-ethyl)-methyl-amide]3-(4-methanesulfonyl-benzylamide),5-((2R)-2-hydroxymethyl-pyrrolidine-1-carbonyl)-6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3-carboxylicacid 3-(4-methanesulfonyl-benzylamide),5-(3-hydroxy-pyrrolidine-1-carbonyl)-6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3,5-dicarboxylicacid 3-(4-methanesulfonyl-benzylamide), N3-[(1,1-dioxido-2,3-dihydro-1-benzothien-5-yl)methyl]-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,5-(N1-acetyl-hydrazinocarbonyl)-6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3-carboxylicacid 4-methanesulfonyl-benzylamide, 5-[N1-(2-cyano-acetyl)-hydrazinocarbonyl]-6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3-carboxylicacid 4-methanesulfonyl-benzylamide,5-{[2-(aminocarbonothioyl)hydrazino]carbonyl}-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-hydrazinocarbonyl-6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3-carboxylic acid4-methanesulfonyl-benzylamide,5-({2-[(ethylamino)carbonyl]hydrazino}carbonyl)-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-({2-[(N,N-dimethylamino)carbonyl]hydrazino}carbonyl)-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(3,3-dimethyl-ureido)-6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3-carboxylicacid 4-methanesulfonyl-benzylamide,6-methyl-5-(3-methyl-ureido)-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3-carboxylic acid4-methanesulfonyl-benzylamide,6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-5-ureido-1,2-dihydro-pyridine-3-carboxylicacid 4-methanesulfonyl-benzylamide,5-amino-6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3-carboxylicacid 4-methanesulfonyl-benzylamide,6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-5-propionyl-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-formyl-6-methyl-N-[4-(methyl sulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-5-(3-oxobutyl)-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-acetyl-N-[4-(isopropylsulfonyl)benzyl]-6-methyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-acetyl-1-(3-cyano-phenyl)-6-methyl-2-oxo-1,2-dihydro-pyridine-3-carboxylicacid 4-methanesulfonyl-benzylamide,5-acetyl-1-(3-chloro-phenyl)-6-methyl-2-oxo-1,2-dihydro-pyridine-3-carboxylicacid 4-methanesulfonyl-benzylamide,5-acetyl-6-methyl-2-oxo-1-m-tolyl-1,2-dihydro-pyridine-3-carboxylic acid4-methanesulfonyl-benzylamide,5-(1-hydroxyethyl)-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(1-azidoethyl)-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,6-methyl-N-[4-(methylsulfonyl)benzyl]-5-(1-morpholin-4-ylethyl)-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(1-hydroxypropyl)-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide, 5-(1-hydroxyethyl)-N-[4-(isopropylsulfonyl)benzyl]-6-methyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,N-[4-(cyclopropylsulfonyl)benzyl]-5-formyl-6-methyl-2-oxo1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-[(E)-(methoxyimino)methyl]-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(hydroxymethyl)-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-[(dimethylamino)methyl]-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,6-methyl-5-[(methylamino)methyl]-N-[4-(methylsulfonyl)benzyl]-2-oxo1-[3-(trifluoromethyl) phenyl]-1,2-dihydropyridine-3-carboxamide,6-methyl-N-[4-(methylsulfonyl)benzyl]-5-(morpholin-4-ylmethyl)-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-{[(2-furylmethyl)amino]methyl}-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-[(cyclopropylamino)methyl]-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-{[(2-hydroxypropyl)amino]methyl}-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide, 5-[(cyclopentylamino)methyl]-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-{[(2-hydroxyethyl)(methyl)amino]methyl}-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-5-(pyrrolidin-1-ylmethyl)-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-{[methoxy(methyl)amino]methyl}-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-{[(cyanomethyl)amino]methyl}-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-{[(cyclopropylmethyl)amino]methyl}-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-[(3-hydroxypyrrolidin-1-yl)methyl]-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(2-hydroxyethoxy)-N-[4-(isopropylsulfonyl)benzyl]-6-methyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,2-methyl-5-({[4-(methylsulfonyl)benzyl]amino}carbonyl)-6-oxo-1-[3-(trifluoromethyl) phenyl]-1,6-dihydropyridin-3-ylacetate, 5-methoxy-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(3-methoxypropoxy)-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,2-methyl-5-({[4-(methylsulfonyl)benzyl]amino}carbonyl)-6-oxo-1-[3-(trifluoromethyl)phenyl]-1,6-dihydropyridin-3-ylmethanesulfonate, 5-ethoxy-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(2-hydroxyethoxy)-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(cyanomethoxy)-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,2-({2-methyl-5-({[4-(methylsulfonyl)benzyl]amino}carbonyl)-6-oxo-1-[3-(trifluoromethyl)phenyl]-1,6-dihydropyridin-3-yl}oxy)ethylacetate,5-[2-(dimethylamino)-2-oxoethoxy]-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(2-aminoethoxy)-N-[4-(isopropylsulfonyl)benzyl]-6-methyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(acetylamino)-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,N-[4-(isopropylsulfonyl)benzyl]-6-methyl-5-[3-(methylamino)propoxy]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(1-methoxyethyl)-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(2-bromo-1-methoxyethyl)-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(1-isopropoxyethyl)-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(N1-isobutyryl-hydrazinocarbonyl)-6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3-carboxylicacid 4-methanesulfonyl-benzylamide, N 5-methoxy-6-methyl-N3-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide, N 5-methoxy-N 5,6-dimethyl-N3-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,5-[(2,5-dimethyl-2,5-dihydro-1H-pyrrol-1-yl)carbonyl]-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide, 6-methyl-N3-[4-(methylsulfonyl)benzyl]-2-oxo-N5-pyrrolidin-1-yl-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-5-(piperidin-1-ylcarbonyl)-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide, 6-methyl-N3-[4-(methylsulfonyl) benzyl]-N5-morpholin-4-yl-2-oxo-1-[3-(trifluoromethyl) phenyl]-1, 2-dihydropyridine-3,5-dicarboxamide,6-methyl-5-[(4-methylpiperidin-1-yl)carbonyl]-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,6-methyl-N 3-[4-(methylsulfonyl)benzyl]-2-oxo-N5-piperidin-1-yl-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5-(tert-butyl)-N 5,6-dimethyl-N3-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5-butyl-N 5,6-dimethyl-N3-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5-ethyl-N 5-isopropyl-6-methyl-N 3-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,5-[N1-(formyl-hydrazinocarbonyl]-6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3-carboxylicacid 4-methanesulfonyl-benzylamide, N1-[5-(4-methanesulfonyl-benzylcarbamoyl)-2-methyl-6-oxo-1-(3-trifluoromethyl-phenyl)-1,6-dihydro-pyridine-3-carbonyl]-hydrazinecarboxylicacid ethyl ester, 5-({2-[(ethylamino)carbonothioyl]hydrazino}carbonyl)-6-methy 1-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(isoxazolidin-2-ylcarbonyl)-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3,5-dicarboxylicacid 5-(methoxy-methyl-amide)3-[4-(propane-2-sulfonyl)-benzylamide],6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3,5-dicarboxylicacid 3-(4-ethanesulfonyl-benzylamide)5-(methoxy-methyl-amide),6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3,5-dicarboxylicacid 3-(4-cyclopropanesulfonyl-benzylamide)5-(methoxy-methyl-amide),6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3,5-dicarboxylicacid 5-[(2-hydroxy-ethyl)-amide]3-(4-methanesulfonyl-benzylamide,5-(isoxazolidine-2-carbonyl)-6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)1,2-dihydro-pyridine-3-carboxylicacid 4-ethanesulfonyl-benzylamide,5-(isoxazolidine-2-carbonyl)-6-methyl-2-oxo-1-(3-trifluoromethylphenyl)1,2dihydropyridine-3-carboxylic acid 4-cyclopropane sulfonylbenzylamide,5-(N-hydroxycarbamimidoyl)-6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3-carboxylic acid4-methanesulfonyl-benzylamide, N 3-(cyclohexylmethyl)-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide, N 5,N5,6-trimethyl-2-oxo-N3-(pyridin-3-ylmethyl)-1-[3-(trifluoromethyl)-phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-N3-(2-morpholin-4-ylethyl)-2-oxo-1-[3-(trifluoromethyl)-phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-N3-(3-morpholin-4-ylpropyl)-2-oxo-1-[3-(trifluoromethyl)-phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 3-benzyl-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydro-pyridine-3,5-dicarboxamide,N 3-[2-(1H-indol-3-yl)ethyl]-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)-phenyl]-1,2-dihydropyridine-3,5-dicarboxamide, N 5,N 5,6-trimethyl-2-oxo-N3-(1-phenylethyl)-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-2-oxo-N3-(2-phenylethyl)-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-2-oxo-N3-[(2R)-2-phenylcyclopropyl]-1-[3-(trifluoromethyl)-phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 3-(2,3-dihydro-1H-inden-2-yl)-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)-phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 3-[2-(1,3-benzodioxol-5-yl)ethyl]-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,5-{[4-(2-hydroxyethyl)piperazin-1-yl]carbonyl}-N,N,2-trimethyl-6-oxo-1-[3-(trifluoromethyl)phenyl]-1,6-dihydropyridine-3-carboxamide,N 3-[(1-ethylpyrrolidin-2-yl)methyl]-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-N3-[3-(2-methylpiperidin-1-yl)propyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-N3-(1-naphthylmethyl)-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 3-(1,3-benzodioxol-5-ylmethyl)-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide, N3-(3,4-difluorobenzyl)-N 5,N 5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 3-(2-chloro-4-fluorobenzyl)-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)-phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-2-oxo-N3-(2-thienylmethyl)-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide, N 3-(3,4-dichlorobenzyl)-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 3-[2-(2,4-dichlorophenyl)ethyl]-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)-phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 3-(2-cyclohex-1-en-1-ylethyl)-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)-phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 3-[1-(4-chlorophenyl)ethyl]-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)-phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-2-oxo-N3-[3-(2-oxopyrrolidin-1-yl)propyl]-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-2-oxo-N3-(pyridin-4-ylmethyl)-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N,N,2-trimethyl-6-oxo-5-[(4-phenylpiperazin-1-yl)carbonyl]-1-[3-(trifluoromethyl)phenyl]-1,6-dihydropyridine-3-carboxamide,N,N,2-trimethyl-6-oxo-5-[(4-pyridin-2-ylpiperazin-1-yl)carbonyl]-1-[3-(trifluoromethyl)phenyl]-1,6-dihydropyridine-3-carboxamide,N 3-(2,3-dihydro-1-benzofuran-5-ylmethyl)-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,methyl4-{[({5-[(dimethylamino)carbonyl]-6-methyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridin-3-yl}carbonyl)amino]methyl}benzoate,5-{[3-(dimethylamino)pyrrolidin-1-yl]carbonyl}-N,N,2-trimethyl-6-oxo-1-[3-(trifluoromethyl)phenyl]-1,6-dihydropyridine-3-carboxamide,N 5,N 5,6-trimethyl-2-oxo-N3-[2-(2-thienyl)ethyl]-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide, N 5,N 5,6-trimethyl-2-oxo-N3-(4-phenoxybenzyl)-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-2-oxo-N3-(3-thienylmethyl)-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 3-[2-(4-tert-butylphenyl)ethyl]-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)-phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 3-{2-[4-(amino sulfonyl)phenyl]ethyl}-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-2-oxo-N3-[4-(1H-pyrazol-1-yl)benzyl]-1-[3-(trifluoromethyl)-phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-2-oxo-N3-phenoxy-1-[3-(trifluoromethyl)phenyl]-1,2-dihydro-pyridine-3,5-dicarboxamide,N 3-(2,3-dihydro-1,4-benzodioxin-2-ylmethyl)-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 3-[(6-fluoro-4H-1,3-benzodioxin-8-yl)methyl]-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 3-(1-benzothien-3-ylmethyl)-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)-phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-2-oxo-N3-[2-(tetrahydro-2H-pyran-4-yl)ethyl]-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-N3-[(1-methyl-1H-pyrazol-4-yl)methyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-2-oxo-N3-[(1-phenyl-1H-pyrazol-4-yl)methyl]-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 3-[(5-methoxy-4-oxo-4H-pyran-2-yl)methyl]-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 3-(3-azepan-1-ylpropyl)-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 3-(4-cyanobenzyl)-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,N 5,N 5,6-trimethyl-2-oxo-N3-[3-(5-oxo-4,5-dihydro-1H-pyrazol-4-yl)propyl]-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide, N3-{[(2R)-1-ethylpyrrolidin-2-yl]methyl}-N 5,N5,6-trimethyl-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3,5-dicarboxamide,5-cyclopropyl-6-methyl-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,6-methyl-5-(2-methyl-1,3-dioxolan-2-yl)-N-[4-(methylsulfonyl)benzyl]-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,5-(4,5-dihydro-oxazol-2-yl)-6-methyl-2-oxo-1-(3-trifluoromethyl-phenyl)-1,2-dihydro-pyridine-3-carboxylicacid 4-methanesulfonyl-benzylamide,5-cyclopropyl-6-methyl-N-{[5-(methylsulfonyl)pyridin-2-yl]methyl}-2-oxo-1-[3-(trifluoromethyl)phenyl]-1,2-dihydropyridine-3-carboxamide,2-amino-3-(3-hydroxy-4-oxopyridin-1-yl)propanoic acid,(2S)-2-amino-3-(3-hydroxy-4-oxopyridin-1-yl)propanoic acid,2-amino-3-(3-hydroxy-4-oxopyridin-1-yl)propanoic acid,(2S)-2-amino-3-(3-hydroxy-4-oxopyridin-1-yl)propanoic acid,2-amino-3-(3-hydroxy-4-oxopyridin-1-yl)propanoic acid,2-amino-3-(3-hydroxy-4-oxopyridin-1-yl)propanoic acid, propyl2-(3,5-diiodo-4-oxopyridin-1-yl)acetate,(2S)-2-azaniumyl-3-(3-hydroxy-4-oxopyridin-1-yl)propanoate, propyl2-(3,5-diiodo-4-oxopyridin-1-yl)acetate, 2-(4-aminophenyl)ethanol,4-hydroxy-5-(3-methylanilino)-1H-pyrimidin-6-one,6-cyclohexyl-1-hydroxy-4-methylpyridin-2-one,1,6-dimethyl-2-oxo-5-pyridin-4-ylpyridine-3-carbonitrile,(2-oxo-1H-pyridin-3-yl) acetate,3-methyl-1-(2,4,6-trimethylphenyl)butan-1-one,5-methyl-1-phenylpyridin-2-one,6-cyclohexyl-1-hydroxy-4-methylpyridin-2-one, 2-aminoethanol;6-cyclohexyl-1-hydroxy-4-methylpyridin-2-one,4-[(3,5-diiodo-4-oxopyridin-1-yl)methyl]benzoic acid, 2-aminoethanol;3-[(6-hydroxy-5-methyl-2-oxo-1H-pyridin-3-yl)imino]-5-methylpyridine-2,6-dione,5-ethyl-3-[(5-ethyl-2-methoxy-6-methylpyridin-3-yl)methylamino]-6-methyl-1H-pyridin-2-one,6-cyclohexyl-1-hydroxy-4-methyl pyridin-2-one,5-(2,5-dihydroxyphenyl)-1H-pyridin-2-one,6-(4,4-dimethyl-5-oxofuran-2-yl)-1H-pyridin-2-one,N′-(6-oxo-1H-pyridin-2-yl)-N,N-dipropyl methanimidamide,[6-oxo-1-[(2R,3R,4S,5S,6R)-3,4,5-trihydroxy-6-(hydroxylmethyl)oxan-2-yl]pyridin-2-yl]acetic acid,5-(2,5-dihydroxyphenyl)-H-pyridin-2-one,3-[(6-hydroxy-5-methyl-2-oxo-H-pyridin-3-yl)imino]-5-methylpyridine-2,6-dione,5-(4-cyanophenyl)-6-methyl-2-oxo-1H-pyridine-3-carbonitrile,3,3-diethyl-1-[(piperazin-1-ylamino)methyl]pyridine-2,4-dione,5-ethyl-3-[(5-ethyl-2-methoxy-6-methylpyridin-3-yl)methylamino]-6-methyl-1H-pyridin-2-oneand pharmaceutically acceptable salts thereof.

In some embodiments, the pirfendione or pyridone analog compound is usedin compositions and methods described herein in free-base or free-acidform. In other embodiments, the pirfendione or pyridone analog compoundis used as pharmaceutically acceptable salts. In some embodiments,pharmaceutically acceptable salts are obtained by reacting the compoundwith an acid or with a base. The type of pharmaceutical acceptablesalts, include, but are not limited to: (1) acid addition salts, formedby reacting the free base form of the compound with a pharmaceuticallyacceptable: (1) acid such as, for example, hydrochloric acid,hydrobromic acid, sulfuric acid, phosphoric acid, metaphosphoric acid,acetic acid, propionic acid, hexanoic acid, cyclopentanepropionic acid,glycolic acid, pyruvic acid, lactic acid, malonic acid, succinic acid,malic acid, maleic acid, fumaric acid, trifluoroacetic acid, tartaricacid, citric acid, benzoic acid, 3-(4-hydroxybenzoyl)benzoic acid,cinnamic acid, mandelic acid, methanesulfonic acid, ethanesulfonic acid,1,2-ethanedisulfonic acid, 2-hydroxyethanesulfonic acid, benzenesulfonicacid, toluenesulfonic acid, 2-naphthalenesulfonic acid,4-methylbicyclo-[2.2.2]oct-2-ene-1-carboxylic acid, glucoheptonic acid,4,4′-methylenebis-(3-hydroxy-2-ene-1-carboxylic acid), 3-phenylpropionicacid, trimethylacetic acid, tertiary butylacetic acid, lauryl sulfuricacid, gluconic acid, glutamic acid, hydroxynaphthoic acid, salicylicacid, stearic acid, muconic acid, butyric acid, phenylacetic acid,phenylbutyric acid, valproic acid, and the like; or (2) base, where anacidic proton present in the parent compound is replaced by a metal ion,e.g., an alkali metal ion (e.g. lithium, sodium, potassium), an alkalineearth ion (e.g. magnesium, or calcium), or an aluminum ion. In somecases, the pirfendione or pyridone analog compound is reacted with anorganic base, such as, but not limited to, ethanolamine, diethanolamine,triethanolamine, tromethamine, N-methylglucamine, dicyclohexylamine,tris(hydroxymethyl)methylamine or with an amino acid such as, but notlimited to, arginine, lysine, and the like.

Advantages of Inhaled Aerosol and Topical (Non-Oral) Drug Delivery

Inhalation therapy of aerosolized pirfenidone or a pyridone analogcompound enables direct deposition of the sustained-release or activesubstance in the respiratory tract (be that intra-nasal or pulmonary)for therapeutic action at that site of deposition or systemic absorptionto regions immediately down stream of the vascular absorption site. Inthe case of central nervous system (CNS) deposition, intra-nasalinhalation aerosol delivery deposits pirfenidone or a pyridone analogcompound directly upstream of the CNS compartment.

Similar to the intra-nasal and pulmonary applications described above,treatment or prevention of organs outside the respiratory tract requiresabsorption to the systemic vascular department for transport to theseextra-respiratory sites. In the case of treating or preventing fibroticor inflammatory diseases associated with the heart, liver and kidney,deposition of drug in the respiratory tract, more specifically the deeplung will enable direct access to these organs through the left atriumto either the carotid arteries or coronary arteries. Similarly, in thecase of treating CNS disorder (e.g., multiple sclerosis), deposition ofdrug in the respiratory tract (as defined above) or nasal cavity, morespecifically the absorption from the nasal cavity to the nasal capillarybeds for immediate access to the brain and CNS. This direct deliverywill permit direct dosing of high concentration pirfenidone or apyridone analog compound in the absence of unnecessary systemicexposure. Similarly, this route permits titration of the dose to a levelthat may be critical for these indications.

Pharmaceutical Compositions

For purposes of the method described herein, a pyridone analog compound,most preferably pirfenidone may be administered using a liquidnebulization, dry powder or metered-dose inhaler. In some embodiments,pirfenidone or a pyridone analog compound disclosed herein is producedas a pharmaceutical composition suitable for aerosol formation, dose forindication, deposition location, pulmonary or intra-nasal delivery forpulmonary, intranasal/sinus, or extra-respiratory therapeutic action,good taste, manufacturing and storage stability, and patient safety andtolerability.

In some embodiments, the isoform content of the manufactured pyridoneanalog compound, most preferably pirfenidone may be optimized for drugsubstance and drug product stability, dissolution (in the case of drypowder or suspension formulations) in the nose and/or lung,tolerability, and site of action (be that lung, nasal/sinus, or regionaltissue).

Manufacture

In some embodiments, pirfenidone drug product (DP) includes pirfenidoneat a concentration of about 1 mg/mL to about 100 mg/mL in aqueous buffer(citrate or phosphate pH=4 to 8), plus optional added salts (NaCl and/orMgCl₂ and/or MgSO₄). In some embodiments, the pirfenidone drug productalso includes co-solvent(s) (by non-limiting example ethanol, propyleneglycol, and glycerin) and/or surfactant(s) (by non-limiting exampleTween 80, Tween 60, lecithin, Cetylpyridinium, and Tween 20). In someembodiments, the formulation also includes a taste-masking agent (bynon-limiting example sodium saccharin).

To achieve pirfenidone concentrations above 3 mg/mL, manufacturingprocess are described. In one embodiment, the manufacturing processincludes high temperature pirfenidone aqueous dissolution, followed byco-solvent and/or surfactant and/or salt addition, and subsequentcooling to ambient temperature. In this process, added co-solvent and/orsurfactant and/or salt stabilize the high-temperature-dissolvedpirfenidone during the cooling process and provide a stable,high-concentration, ambient-temperature formulation of pirfenidone. Insome embodiments, the processing temperature is 30° C., 35° C., 40° C.,45° C., 50° C., 55° C., 60° C., 65° C., 70° C., 75° C., 80° C., 85° C.,90° C., 95° C., 100° C. or other pressure-enabled increased temperature.In some embodiments, the process includes addition of surfactant and/orco-solvent and/or salt at the highest temperature or incrementally-lowertemperature as the solution is cooled. In some embodiments, addition ofsurfactant and/or co-solvent and/or salt occurs all at once orincrementally during a maintained temperature or as the solution iscooled. The time by which the solution is maintained at the highesttemperature is from 0 minutes to 24 hours. The time by which thesolution is cooled from the highest temperature is from 0 minutes to 24hours. In some embodiments, the solution is protected from light. Insome embodiments, the solution is sparged to remove or lower the oxygenconcentration. In some embodiments, the head space of the reactioncontainer includes an inert gas or mixture of inert gases. Inert gasesinclude, but are not limited to, nitrogen and argon. In someembodiments, the pirfenidone drug product includes co-solvent(s) in theconcentration range of 0% to 100% in otherwise buffered aqueoussolution. In some embodiments, the pirfenidone drug product includesco-solvent(s) at a concentration of about 1% to about 25%. Co-solventsinclude, but are not limited to, ethanol, glycerin or propylene glycol.In some embodiments, the pirfenidone drug product includes surfactant(s)in the concentration range of 0% to 100% in otherwise buffered aqueoussolution. In some embodiments, the pirfenidone drug product includessurfactant(s) at a concentration of about 0.1% to about 10%. Surfactantsinclude, but are not limited to Tween 20, Tween 60, Tween 80,Cetylpyridinium Bromide, or Lecithin. In some embodiments, thepirfenidone drug product includes a buffer. In some embodiments, thebuffer includes salt and/or acid forms of agents such as citrate,phosphate or formate at a concentration between 0 mM to 1000 mM. In someembodiments, the buffer includes salt and/or acid forms of agents suchas citrate, phosphate or formate at a concentration between about 1 mMand about 50 mM. In some embodiments, the pirfenidone drug productincludes a salt. In some embodiments, the salt is present at aconcentration between 0% to 100%. In some embodiments, the salt ispresent at a concentration between about 0.1% and about 5%. In someembodiments, the salt is sodium chloride, magnesium chloride, magnesiumsulfate or barium chloride. In some embodiments, a sweetening agent isadded to the pirfenidone drug product. In some embodiments, thesweetening agent is saccharin or a salt thereof. In some embodiments,the sweetening agent is present at a concentration between about 0.01 mMand about 10 mM. In some embodiments, the pH of the buffered solutionwill be between about 2.0 and about 10.0.

In another embodiment, the manufacturing process includes excessco-solvent and/or surfactant and/or cation addition to a super-saturatedpirfenidone aqueous solution. Upon dissolution in the excess co-solventand/or surfactant and/or cation aqueous solution, the formulation isdiluted to reduce co-solvent and/or surfactant and/or cationconcentrations to within the concentration range generally-recognized assafe and/or non-toxic and/or non-irritable.

In some embodiments, the manufacturing process is as described inExample 5.

Administration

The pyridone analog compound, most preferably pirfenidone as disclosedherein can be administered at a therapeutically effective dosage, e.g.,a dosage sufficient to provide treatment for the disease statespreviously described. Generally, for example, a daily aerosol dose ofpirfenidone in a pirfenidone compound formulation may be from about0.001 mg to about 6.6 mg pirfenidone/kg of body weigh per dose. Thus,for administration to a 70 kg person, the dosage range would be about0.07 mg to about 463 mg pirfenidone per dose or up to about 0.280 mg toabout 1852 mg pirfenidone day. The amount of active compoundadministered will, of course, be dependent on the subject and diseasestate being treated, the severity of the affliction, the manner andschedule of administration, the location of the disease (e.g., whetherit is desired to effect intra-nasal or upper airway delivery, pharyngealor laryngeal delivery, bronchial delivery, pulmonary delivery and/orpulmonary delivery with subsequent systemic or central nervous systemabsorption), and the judgment of the prescribing physician; for example,a likely dose range for aerosol administration of pirfenidone inpreferred embodiments, or in other embodiments of pyridone analogcompound, would be about 0.28 to 1852 mg per day.

Another unexpected observation is that inhalation delivery of aerosolpirfenidone to the lung exhibits less metabolism of pirfenidone observedwith oral administration. Thus, oral or intranasal inhalation ofpirfenidone or pyridone analog will permit maximum levels of activesubstance to the pulmonary tissue in the absence of substantialmetabolism to inactive agents.

Inhibitors of CYP enzymes reduce pirfenidone metabolism resulting inelevated blood levels and associated toxicity. As many productseffecting CYP enzymes are useful to fibrosis patients, permitting theiruse would be beneficial. While the oral route is already at the maximumpermissible dose (which provides only moderate efficacy), any inhibitionof the enzymes described above elevates pirfenidone blood levels andincreases the rate and severity of the toxic events described herein.Because oral and intranasal inhalation delivery of pirfenidone orpyridone analogs can achieve effective tissue levels with much less drugthan that required by the oral product, resulting blood levels aresignificantly lower and consequences associated with CYP enzymeinhibitory properties described herein are removed. Thus, permitting useof these CYP inhibitory enzyme products currently contraindicated withthe oral medicine.

The primary metabolite of pirfenidone is 5-carboxy-pirfenidone.Following oral or intravenous administration, this metabolite appearsquickly at high concentrations in blood. 5-carboxy-pirfenidone does notappear to have anti-fibrotic or anti-inflammatory activity, its highblood levels occur at the loss of pirfenidone blood concentrations.Thus, while the oral product is dosed at the highest possible level,once pirfenidone enters the blood it is rapidly metabolized to anon-active species further reducing the drugs potential to achievesufficient lung levels required for substantial efficacy. Because oraland intranasal inhalation delivery of pirfenidone or pyridone analogscan achieve effective lung tissue levels directly extra-lung metabolismis not a factor.

Administration of the pyridone analog compound, most preferablypirfenidone as disclosed herein, such as a pharmaceutically acceptablesalt thereof, can be via any of the accepted modes of administration foragents that serve similar utilities including, but not limited to,aerosol inhalation such as nasal and/or oral inhalation of a mist orspray containing liquid particles, for example, as delivered by anebulizer.

Pharmaceutically acceptable compositions thus may include solid,semi-solid, liquid and aerosol dosage forms, such as, e.g., powders,liquids, suspensions, complexations, liposomes, particulates, or thelike. Preferably, the compositions are provided in unit dosage formssuitable for single administration of a precise dose. The unit dosageform can also be assembled and packaged together to provide a patientwith a weekly or monthly supply and can also incorporate other compoundssuch as saline, taste masking agents, pharmaceutical excipients, andother active ingredients or carriers.

The pyridone analog compound, most preferably pirfenidone as disclosedherein, such as a pharmaceutically acceptable salt thereof, can beadministered either alone or more typically in combination with aconventional pharmaceutical carrier, excipient or the like (e.g.,mannitol, lactose, starch, magnesium stearate, sodium saccharin, talcum,cellulose, sodium crosscarmellose, glucose, gelatin, sucrose, magnesiumcarbonate, magnesium chloride, magnesium sulfate, calcium chloride,lactose, sucrose, glucose and the like). If desired, the pharmaceuticalcomposition can also contain minor amounts of nontoxic auxiliarysubstances such as wetting agents, emulsifying agents, solubilizingagents, pH buffering agents and the like (e.g., citric acid, ascorbicacid, sodium phosphate, potassium phosphate, sodium acetate, sodiumcitrate, cyclodextrin derivatives, sorbitan monolaurate, triethanolamineacetate, triethanolamine oleate, and the like). Generally, depending onthe intended mode of administration, the pharmaceutical formulation willcontain about 0.005% to 95%, preferably about 0.1% to 50% by weight of acompound of the invention. Actual methods of preparing such dosage formsare known, or will be apparent, to those skilled in this art; forexample, see Remington's Pharmaceutical Sciences, Mack PublishingCompany, Easton, Pa.

In one preferred embodiment, the compositions will take the form of aunit dosage form such as vial containing a liquid, solid to besuspended, dry powder, lyophilisate, or other composition and thus thecomposition may contain, along with the active ingredient, a diluentsuch as lactose, sucrose, dicalcium phosphate, or the like; a lubricantsuch as magnesium stearate or the like; and a binder such as starch, gumacacia, polyvinylpyrrolidine, gelatin, cellulose, cellulose derivativesor the like.

Liquid pharmaceutically administrable compositions can, for example, beprepared by dissolving, dispersing, etc. an active compound as definedabove and optional pharmaceutical adjuvants in a carrier (e.g., water,saline, aqueous dextrose, glycerol, glycols, ethanol or the like) toform a solution or suspension. Solutions to be aerosolized can beprepared in conventional forms, either as liquid solutions orsuspensions, as emulsions, or in solid forms suitable for dissolution orsuspension in liquid prior to aerosol production and inhalation. Thepercentage of active compound contained in such aerosol compositions ishighly dependent on the specific nature thereof, as well as the activityof the compound and the needs of the subject. However, percentages ofactive ingredient of 0.01% to 90% in solution are employable, and willbe higher if the composition is a solid, which will be subsequentlydiluted to the above percentages. In some embodiments, the compositionwill comprise 0.25%-50.0% of the active agent in solution.

Pirfenidone or pyridone analog compound formulations can be separatedinto two groups; those of simple formulation and complex formulationsproviding taste-masking for improved tolerability, pH-optimized forstability and tolerability, immediate or sustained-release, and/orarea-under-the-curve (AUC) shape-enhancing properties. Simpleformulations can be further separated into three groups. 1. Simpleformulations may include water-based liquid formulations fornebulization. By non-limiting example water-based liquid formulationsmay consist of pirfenidone or pyridone analog compound alone or withnon-encapsulating water soluble excipients. 2. Simple formulations mayalso include organic-based liquid formulations for nebulization ormeter-dose inhaler. By non-limiting example organic-based liquidformulations may consist of pirfenidone or pyridone analog compound orwith non-encapsulating organic soluble excipients. 3. Simpleformulations may also include dry powder formulations for administrationwith a dry powder inhaler. By non-limiting example dry powderformulations may consist of pirfenidone or pyridone analog compoundalone or with either water soluble or organic soluble non-encapsulatingexcipients with or without a blending agent such as lactose. Complexformulations can be further separated into five groups. 1. Complexformulations may include water-based liquid formulations fornebulization. By non-limiting example water-based liquid complexformulations may consist of pirfenidone or pyridone analog compoundencapsulated or complexed with water-soluble excipients such as lipids,liposomes, cyclodextrins, microencapsulations, and emulsions. 2. Complexformulations may also include organic-based liquid formulations fornebulization or meter-dose inhaler. By non-limiting exampleorganic-based liquid complex formulations may consist of pirfenidone orpyridone analog compound encapsulated or complexed with organic-solubleexcipients such as lipids, microencapsulations, and reverse-phasewater-based emulsions. 3. Complex formulations may also includelow-solubility, water-based liquid formulations for nebulization. Bynon-limiting example low-solubility, water-based liquid complexformulations may consist of pirfenidone or pyridone analog compound as alow-water soluble, stable nanosuspension alone or inco-crystal/co-precipitate excipient complexes, or mixtures with lowsolubility lipids, such as lipid nanosuspensions. 4. Complexformulations may also include low-solubility, organic-based liquidformulations for nebulization or meter-dose inhaler. By non-limitingexample low-solubility, organic-based liquid complex formulations mayconsist of pirfenidone or pyridone analog compound as a low-organicsoluble, stable nanosuspension alone or in co-crystal/co-precipitateexcipient complexes, or mixtures with low solubility lipids, such aslipid nanosuspensions. 5. Complex formulations may also include drypowder formulations for administration using a dry powder inhaler. Bynon-limiting example, complex dry powder formulations may consist ofpirfenidone or pyridone analog compound inco-crystal/co-precipitate/spray dried complex or mixture with low-watersoluble excipients/salts in dry powder form with or without a blendingagent such as lactose. Specific methods for simple and complexformulation preparation are described herein.

Aerosol Delivery

Pirfenidone or pyridone analog compounds as described herein arepreferably directly administered as an aerosol to a site of pulmonarypathology including pulmonary fibrosis, COPD or asthma. The aerosol mayalso be delivered to the pulmonary compartment for absorption into thepulmonary vasculature for therapy or prophylaxis of extra-pulmonarypathologies such as fibrosis and inflammatory diseases of the heart,kidney and liver, or pulmonary or intra-nasal delivery forextra-pulmonary or extra-nasal cavity demylination diseases associatedwith the central nervous system.

Several device technologies exist to deliver either dry powder or liquidaerosolized products. Dry powder formulations generally require lesstime for drug administration, yet longer and more expensive developmentefforts. Conversely, liquid formulations have historically suffered fromlonger administration times, yet have the advantage of shorter and lessexpensive development efforts. Pirfenidone or pyridone analog compoundsdisclosed herein range in solubility, are generally stable and have arange of tastes. In one such embodiment, pirfenidone or pyridone analogcompounds are water soluble at pH 4 to pH 8, are stable in aqueoussolution and have limited to no taste. Such a pyridone includespirfenidone.

Accordingly, in one embodiment, a particular formulation of thepirfenidone or pyridone analog compound disclosed herein is combinedwith a particular aerosolizing device to provide an aerosol forinhalation that is optimized for maximum drug deposition at a site ofinfection, pulmonary arterial hypertension, pulmonary or intra-nasalsite for systemic absorption for extra-nasal and/or extra-pulmonaryindications, and maximal tolerability. Factors that can be optimizedinclude solution or solid particle formulation, rate of delivery, andparticle size and distribution produced by the aerosolizing device.

Particle Size and Distribution

The distribution of aerosol particle/droplet size can be expressed interms of either: the mass median aerodynamic diameter (MMAD)—the dropletsize at which half of the mass of the aerosol is contained in smallerdroplets and half in larger droplets;

volumetric mean diameter (VMD);mass median diameter (MMD);the fine particle fraction (FPF)—the percentage of particles that are <5μm in diameter.

These measures have been used for comparisons of the in vitroperformance of different inhaler device and drug combinations. Ingeneral, the higher the fine particle fraction, the higher theproportion of the emitted dose that is likely to deposit the lung.

Generally, inhaled particles are subject to deposition by one of twomechanisms: impaction, which usually predominates for larger particles,and sedimentation, which is prevalent for smaller particles. Impactionoccurs when the momentum of an inhaled particle is large enough that theparticle does not follow the air stream and encounters a physiologicalsurface. In contrast, sedimentation occurs primarily in the deep lungwhen very small particles which have traveled with the inhaled airstream encounter physiological surfaces as a result of random diffusionwithin the air stream.

For pulmonary administration, the upper airways are avoided in favor ofthe middle and lower airways. Pulmonary drug delivery may beaccomplished by inhalation of an aerosol through the mouth and throat.Particles having a mass median aerodynamic diameter (MMAD) of greaterthan about 5 microns generally do not reach the lung; instead, they tendto impact the back of the throat and are swallowed and possibly orallyabsorbed. Particles having diameters of about 1 to about 5 microns aresmall enough to reach the upper- to mid-pulmonary region (conductingairways), but are too large to reach the alveoli. Smaller particles,i.e., about 0.5 to about 2 microns, are capable of reaching the alveolarregion. Particles having diameters smaller than about 0.5 microns canalso be deposited in the alveolar region by sedimentation, although verysmall particles may be exhaled. Measures of particle size can bereferred to as volumetric mean diameter (VMD), mass median diameter(MMD), or MMAD. These measurements may be made by impaction (MMD andMMAD) or by laser (VMD). For liquid particles, VMD, MMD and MMAD may bethe same if environmental conditions are maintained, e.g., standardhumidity. However, if humidity is not maintained, MMD and MMADdeterminations will be smaller than VMD due to dehydration duringimpactor measurements. For the purposes of this description, VMD, MMDand MMAD measurements are considered to be under standard conditionssuch that descriptions of VMD, MMD and MMAD will be comparable.Similarly, dry powder particle size determinations in MMD and MMAD arealso considered comparable.

In some embodiments, the particle size of the aerosol is optimized tomaximize the pirfenidone or pyridone analog compound deposition at thesite of pulmonary pathology and/or extra-pulmonary, systemic or centralnervous system distribution, and to maximize tolerability (or in thelater case, systemic absorption). Aerosol particle size may be expressedin terms of the mass median aerodynamic diameter (MMAD). Large particles(e.g., MMAD >5 μm) may deposit in the upper airway because they are toolarge to navigate the curvature of the upper airway. Small particles(e.g., MMAD <2 μm) may be poorly deposited in the lower airways and thusbecome exhaled, providing additional opportunity for upper airwaydeposition. Hence, intolerability (e.g., cough and bronchospasm) mayoccur from upper airway deposition from both inhalation impaction oflarge particles and settling of small particles during repeatedinhalation and expiration. Thus, in one embodiment, an optimum particlesize is used (e.g., MMAD=2-5 μm) in order to maximize deposition at amid-lung and to minimize intolerability associated with upper airwaydeposition. Moreover, generation of a defined particle size with limitedgeometric standard deviation (GSD) may optimize deposition andtolerability. Narrow GSD limits the number of particles outside thedesired MMAD size range. In one embodiment, an aerosol containing one ormore compounds disclosed herein is provided having a MMAD from about 2microns to about 5 microns with a GSD of less than or equal to about 2.5microns. In another embodiment, an aerosol having an MMAD from about 2.8microns to about 4.3 microns with a GSD less than or equal to 2 micronsis provided. In another embodiment, an aerosol having an MMAD from about2.5 microns to about 4.5 microns with a GSD less than or equal to 1.8microns is provided.

In some embodiments, the pirfenidone or pyridone analog compound that isintended for respiratory delivery (for either systemic or localdistribution) can be administered as aqueous formulations, assuspensions or solutions in halogenated hydrocarbon propellants, or asdry powders. Aqueous formulations may be aerosolized by liquidnebulizers employing either hydraulic or ultrasonic atomization.Propellant-based systems may use suitable pressurized metered-doseinhalers (pMDIs). Dry powders may use dry powder inhaler devices (DPIs),which are capable of dispersing the drug substance effectively. Adesired particle size and distribution may be obtained by choosing anappropriate device.

Lung Deposition as used herein, refers to the fraction of the nominaldose of an active pharmaceutical ingredient (API) that is bioavailableat a specific site of pharmacologic activity upon administration of theagent to a patient via a specific delivery route. For example, a lungdeposition of 30% means 30% of the active ingredient in the inhalationdevice just prior to administration is deposited in the lung. Likewise,a lung deposition of 60% means 60% of the active ingredient in theinhalation device just prior to administration is deposited in the lung,and so forth. Lung deposition can be determined using methods ofscintigraphy or deconvolution. In some embodiments, the presentinvention provides for methods and inhalation systems for the treatmentor prophylaxis of a respiratory condition in a patient, comprisingadministering to the patient a nominal dose of pirfenidone or a pyridoneanalog compound with a liquid nebulizer. In some embodiments, the liquidnebulizer is a high efficiency liquid nebulizer. In some embodiments alung deposition of pirfenidone or a pyridone analog compound of at leastabout 7%, at least about 10%, at least about 15%, at least about 20%, atleast about 25%, at least about 30%, at least about 35%, at least about40%, at least about 45%, at least about 50%, at least about 55%, atleast about 60%, at least about 65%, at least about 70%, at least about75%, at least about 80%, or at least about 85%, based on the nominaldose of pirfenidone or a pyridone analog compound is achieved.

There are two main methods used to measure aerosol deposition in thelungs. First, γ-scintigraphy is performed by radiolabeling the drug witha substance like 99m-technetium, and scanning the subject afterinhalation of the drug. This technique has the advantage of being ableto quantify the proportion of aerosol inhaled by the patient, as well asregional distribution in the upper airway and lungs. Second, since mostof the drug deposited in the lower airways will be absorbed into thebloodstream, pharmacokinetic techniques are used to measure lungdeposition. This technique can assess the total amount of ICSs thatinteracts with the airway epithelium and is absorbed systemically, butwill miss the small portion that may be expectorated or swallowed aftermucociliary clearance, and cannot tell us about regional distribution.Therefore, γ-scintigraphy and pharmacokinetic studies are in many casesconsidered complementary.

In some embodiments, administration of the pirfenidone or pyridoneanalog compound with a liquid nebulizer provides a GSD of emitteddroplet size distribution of about 1.0 μm to about 2.5 m, about 1.2 kmto about 2.0 m, or about 1.0 km to about 2.0 km. In some embodiments,the MMAD is about 0.5 μm to about 5 m, or about 1 to about 4 m or lessthan about 5 km. In some embodiments, the VMD is about 0.5 μm to about 5μm, or about 1 to about 4 μm or less than about 5 km.

Fine Particle Fraction (FPF) describes the efficiency of a nebulizerinhalation device. FPF represents the percentage of the deliveredaerosol dose, or inhaled mass, with droplets of diameter less than 5.0μm. Droplets of less than 5.0 μm in diameter are considered to penetrateto the lung. In some embodiments, administration of an aqueousinhalation pirfenidone or pyridone analog solution with a liquidnebulizer provides a RDD of at least about 30%, at least about 35%, atleast about 40%, at least about 45%, at least about 50%, at least about55%, at least about 60%, at least about 65%, at least about 70%, atleast about 75%, or at least about 80%.

The Delivered Dose (DD) of drug to a patient is the certain portion ofvolume of liquid filled into the nebulizer, i.e. the fill volume, whichis emitted from the mouthpiece of the device. The difference between thenominal dose and the DD is the amount of volume lost primarily toresidues, i.e. the amount of fill volume remaining in the nebulizerafter administration, or is lost in aerosol form during expiration ofair from the patient and therefore not deposited in the patient's body.In some embodiments, the DD of the nebulized formulations describedherein is at least about 30%, at least about 35%, at least about 40%, atleast about 45%, at least about 50%, at least about 55%, at least about60%, at least about 65%, at least about 70%, or at least about 80%.

The Respirable Delivered Dose (RDD) is an expression of the deliveredmass of drug contained within emitted droplets from a nebulizer that aresmall enough to reach and deposit on the surface epithelium of thepatients lung. The RDD is determined by multiplying the DD by the FPF.

In one embodiment, described herein an aqueous droplet containingpirfenidone or pyridone analog compound, wherein the aqueous droplet hasa diameter less than about 5.0 μm. In some embodiments, the aqueousdroplet has a diameter less than about 5.0 μm, less than about 4.5 m,less than about 4.0 m, less than about 3.5 am, less than about 3.0 am,less than about 2.5 μm, less than about 2.0 μm, less than about 1.5 μm,or less than about 1.0 μm. In some embodiments, the aqueous dropletfurther comprises one or more colsolvents. In some embodiments, the oneor more cosolvents are selected from ethanol and propylene glycol. Insome embodiments, the aqueous droplet further comprises a buffer. Insome embodiments, the buffer is a citrate buffer or a phosphate buffer.In some embodiments, the dioplet was produced from a liquid nebulizerand an aqueous solution of pirfenidone or pyridone analog compound asdescribed herein. In some embodiments, the aqueous droplet was producedfrom an aqueous solution that has concentration of pirfenidone orpyridone analog compound between about 0.1 mg/mL and about 60 mg/mL andan osmolality from about 50 mOsmol/kg to about 6000 mOsmol/kg. In someembodiments, the osmolality is greater than about 100 mOsmol/kg. In someembodiments, the osmolality is greater than about 400 mOsmol/kg. In someembodiments, the osmolality is greater than about 1000 mOsmol/kg. Insome embodiments, the osmolality is greater than about 2000 mOsmol/kg.In some embodiments, the osmolality is greater than about 3000mOsmol/kg. In some embodiments, the osmolality is greater than about4000 mOsmol/kg. In some embodiments, the osmolality is greater thanabout 5000 mOsmol/kg.

Also described are aqueous aerosols comprising a plurality of aqueousdroplets of pirfenidone or pyridone analog compound as described herein.In some embodiments, the at least about 30% of the aqueous droplets inthe aerosol have a diameter less than about 5 m. In some embodiments, atleast about 35%, at least about 40%, at least about 45%, at least about50%, at least about 55%, at least about 60%, at least about 65%, atleast about 70%, at least about 75%, at least about 80%, at least about85%, or at least about 90% of the aqueous droplets in the aerosol have adiameter less than about 5 am. In some embodiments, the aqueous aerosolsare produced with a liquid nebulizer. In some embodiments, the aqueousaerosols are produced with a high efficiency liquid nebulizer.

Liquid Nebulizer

In one embodiment, a nebulizer is selected on the basis of allowing theformation of an aerosol of a pirfenidone or pyridone analog compounddisclosed herein having an MMAD predominantly between about 1 to about 5microns. In one embodiment, the delivered amount of pirfenidone orpyridone analog compound provides a therapeutic effect for pulmonarypathology and/or extra-pulmonary, systemic, tissue or central nervoussystem distribution.

Previously, two types of nebulizers, jet and ultrasonic, have been shownto be able to produce and deliver aerosol particles having sizes between2 and 4 micron. These particle sizes have been shown as being optimalfor middle airway deposition. However, unless a specially formulatedsolution is used, these nebulizers typically need larger volumes toadminister sufficient amount of drug to obtain a therapeutic effect. Ajet nebulizer utilizes air pressure breakage of an aqueous solution intoaerosol droplets. An ultrasonic nebulizer utilizes shearing of theaqueous solution by a piezoelectric crystal. Typically, however, the jetnebulizers are only about 10% efficient under clinical conditions, whilethe ultrasonic nebulizer is only about 5% efficient. The amount ofpharmaceutical deposited and absorbed in the lungs is thus a fraction ofthe 10% in spite of the large amounts of the drug placed in thenebulizer. The amount of drug that is placed in the nebulizer prior toadministration to the mammal is generally referred to the “nominaldose,” or “loaded dose.” The volume of solution containing the nominaldose is referred to as the “fill volume.” Smaller particle sizes or slowinhalation rates permit deep lung deposition. In addition to slowinhalation, devices such as the Philips Ineb Adaptive Aerosol Delivery(AAD) System and the Activaero Flow And Volume Regulated InhalationTechnology (FAVORITE) use controlled device features to assistinspiratory flow to maximize delivery efficiency, peripheral depositionand improve dose reproducibility while reducing side effects. Bothmiddle-lung and alveolar deposition may be desired for this inventiondepending on the indication, e.g., middle and/or alveolar deposition forpulmonary fibrosis and systemic delivery. Exemplary disclosure ofcompositions and methods for formulation delivery using nebulizers canbe found in, e.g., US 2006/0276483, including descriptions oftechniques, protocols and characterization of aerosolized mist deliveryusing a vibrating mesh nebulizer.

Accordingly, in one embodiment, a vibrating mesh nebulizer is used todeliver in preferred embodiments an aerosol of the pirfenidone compoundas disclosed herein, or in other embodiments, a pyridone analog compoundas disclosed herein. A vibrating mesh nebulizer comprises a liquidstorage container in fluid contact with a diaphragm and inhalation andexhalation valves. In one embodiment, about 1 to about 6 ml of thepirfenidone compound formulation (or in another related embodiment, of apyridone analog compound formulation) is placed in the storage containerand the aerosol generator is engaged producing atomized aerosol ofparticle sizes selectively between about 1 and about 5 micron. In oneembodiment, about 1 to about 10 mL of the pirfenidone compoundformulation (or in another related embodiment, of a pyridone analogcompound formulation) is placed in the storage container and the aerosolgenerator is engaged producing atomized aerosol of particle sizesselectively between about 1 and about 5 micron. In one embodiment, aboutthe volume of the pirfenidone compound formulation (or in anotherrelated embodiment, of a pyridone analog compound formulation) that isoriginally placed in the storage container and the aerosol generator isreplaced to increase the administered dose size.

In some embodiments a pirfenidone or pyridone analog compoundformulation as disclosed herein, is placed in a liquid nebulizationinhaler and prepared in dosages to deliver from about 34 mcg to about463 mg from a dosing solution of about 0.5 to about 6 ml with MMADparticles sizes between about 1 to about 5 micron being produced.

In some embodiments a pirfenidone or pyridone analog compoundformulation as disclosed herein, is placed in a liquid nebulizationinhaler and prepared in dosages to deliver from about 34 mcg to about463 mg from a dosing solution of about 0.5 to about 7 ml with MMADparticles sizes between about 1 to about 5 micron being produced.

By non-limiting example, a nebulized pirfenidone or pyridone analogcompound may be administered in the described respirable delivered dosein less than about 20 min, less than about 15 min, less than about 10min, less than about 7 min, less than about 5 min, less than about 3min, or less than about 2 min.

By non-limiting example, a nebulized pirfenidone or pyridone analogcompound may be administered in the described respirable delivered doseusing a breath-actuated nebulizer in less than about 20 min, less thanabout 10 min, less than about 7 min, less than about 5 min, less thanabout 3 min, or less than about 2 min.

By non-limiting example, in other circumstances, a nebulized pirfenidoneor pyridone analog compound may achieve improved tolerability and/orexhibit an area-under-the-curve (AUC) shape-enhancing characteristicwhen administered over longer periods of time. Under these conditions,the described respirable delivered dose in more than about 2 min,preferably more than about 3 min, more preferably more than about 5 min,more preferably more than about 7 min, more preferably more than about10 min, and in some cases most preferable from about 10 to about 20 min.

As disclosed herein, there is provided a pyridone analog compoundformulation composition comprising a pirfenidone compound aqueoussolution having a pH from about 4.0 to about pH 8.0 where thepirfenidone compound is present at a concentration from about 34 mcg/mLto about 463 mg/mL pirfenidone. In certain other embodiments thepirfenidone compound formulation is provided as an aqueous solutionhaving a pH of from about 4.0 to about 8.0, the solution comprising apirfenidone compound at a concentration of from about 34 mcg/mL to about463 mg/mL pirfenidone; and citrate buffer or phosphate buffer at aconcentration of from about 0 mM to about 50 mM. In certain otherembodiments the pirfenidone compound formulation is provided as anaqueous solution having a pH of from about 4.0 to about 8.0, thesolution comprising a pirfenidone compound at a concentration of fromabout 34 mcg/mL to about 463 mg/mL pirfenidone; and a buffer that has apKa between 4.7 and 6.8 and that is present at a concentrationsufficient to maintain or maintain after titration with acid or base apH from about 4.0 to about 8.0 for a time period sufficient to enablemarketable product shelf-life storage.

In some embodiments, described herein is a pharmaceutical compositionthat includes: pirfenidone; water; phosphate buffer or citrate buffer;and optionally sodium chloride or magnesium chloride. In otherembodiments, described herein is a pharmaceutical composition thatincludes: pirfenidone; water; a buffer; and at least one additionalingredient selected from sodium chloride, magnesium chloride, ethanol,propylene glycol, glycerol, polysorbate 80, and cetylpyridinium bromide(or chloride). In some embodiments, the buffer is phosphate buffer. Inother embodiments, the buffer is citrate buffer. In some embodiments,the pharmaceutical composition includes 1 mg to 500 mg of pirfenidone,for example, 5 mg, 10 mg, 15 mg, 25 mg, 37.5 mg, 75 mg, 100 mg, 115 mg,150 mg, 190 mg, 220 mg, or 500 mg. In some embodiments, the osmolalityof the pharmaceutical composition described herein is between about 50mOsmo/kg to 6000 mOsmo/kg. In some embodiments, the osmolality of thepharmaceutical composition described herein is between about 50 mOsmo/kgto 5000 mOsmo/kg. In some embodiments, the pharmaceutical compositionoptionally includes saccharin (e.g. sodium salt). In some embodiments,such a pharmaceutical composition is placed in a liquid nebulizationinhaler to deliver from about 1 mg to about 500 mg from a dosingsolution of about 0.5 to about 6 mL with MMAD particles sizes betweenabout 1 to about 5 micron being produced. In some embodiments, such apharmaceutical composition is placed in a liquid nebulization inhaler todeliver from about 1 mg to about 500 mg from a dosing solution of about0.5 to about 7 mL with MMAD particles sizes between about 1 to about 5micron being produced. In some embodiments such a nebulizedpharmaceutical composition may deliver between about 0.0001 mg and about25 mg pirfenidone or pyridone analog in aerosol particles with a MMADbetween 1 and 5 microns in each inhaled breath. In some embodiments, 1mg pirfenidone or pyridone analog delivered in 10 breaths over 1 minute,whereby 50% of the inhaled particles are between 1 and 5 microns, 0.05mg pirfenidone or pyridine analog will be delivered in each breath. Insome embodiments, 1 mg pirfenidone or pyridone analog delivered in 15breaths per minute over 10 minutes, whereby 50% of the inhaled particlesare between 1 and 5 microns, 0.0033 mg pirfenidone or pyridone analogwill be delivered in each breath. In some embodiments, 1 mg pirfenidoneor pyridone analog delivered in 20 breaths per minute over 20 minutes,whereby 50% of the inhaled particles are between 1 and 5 microns,0.00125 mg pirfenidone or pyridone analog will be delivered in eachbreath. In some embodiments, 200 mg pirfenidone or pyridone analogdelivered in 10 breaths over 1 minute, whereby 50% of the inhaledparticles are between 1 and 5 microns, 10 mg pirfenidone or pyridoneanalog will be delivered in each breath. In some embodiments, 200 mgpirfenidone or pyridone analog delivered in 15 breaths per minute over10 minutes, whereby 50% of the inhaled particles are between 1 and 5microns, 0.67 mg pirfenidone or pyridone analog will be delivered ineach breath. By another non-limiting example, In some embodiments, 200mg pirfenidone or pyridone analog delivered in 20 breaths per minuteover 20 minutes, whereby 50% of the inhaled particles are between 1 and5 microns, 0.25 mg pirfenidone or pyridone analog will be delivered ineach breath. In some embodiments, 500 mg pirfenidone or pyridine analogdelivered in 10 breaths over 1 minute, whereby 50% of the inhaledparticles are between 1 and 5 microns, 25 mg pirfenidone or pyridoneanalog will be delivered in each breath. In some embodiments, 500 mgpirfenidone or pyridone analog delivered in 15 breaths per minute over10 minutes, whereby 50% of the inhaled particles are between 1 and 5microns, 1.67 mg pirfenidone or pyridone analog will be delivered ineach breath. In some embodiments, 500 mg pirfenidone or pyridone analogdelivered in 20 breaths per minute over 20 minutes, whereby 50% of theinhaled particles are between 1 and 5 microns, 0.625 mg pirfenidone orpyridone analog will be delivered in each breath.

In some embodiments, a nebulized pirfenidone or pyridone analog compoundmay be administered in the described respirable delivered dose in lessthan about 20 min, less than about 10 min, less than about 7 min, lessthan about 5 min, less than about 3 min, or less than about 2 min.

For aqueous and other non-pressurized liquid systems, a variety ofnebulizers (including small volume nebulizers) are available toaerosolize the formulations. Compressor-driven nebulizers incorporatejet technology and use compressed air to generate the liquid aerosol.Such devices are commercially available from, for example, HealthdyneTechnologies, Inc.; Invacare, Inc.; Mountain Medical Equipment, Inc.;Pari Respiratory, Inc.; Mada Medical, Inc.; Puritan-Bennet; Schuco,Inc., DeVilbiss Health Care, Inc.; and Hospitak, Inc. Ultrasonicnebulizers rely on mechanical energy in the form of vibration of apiezoelectric crystal to generate respirable liquid droplets and arecommercially available from, for example, Omron Heathcare, Inc.,Boehringer Ingelheim, and DeVilbiss Health Care, Inc. Vibrating meshnebulizers rely upon either piezoelectric or mechanical pulses torespirable liquid droplets generate. Other examples of nebulizers foruse with pirfenidone or pyridone analogs described herein are describedin U.S. Pat. Nos. 4,268,460; 4,253,468; 4,046,146; 3,826,255; 4,649,911;4,510,929; 4,624,251; 5,164,740; 5,586,550; 5,758,637; 6,644,304;6,338,443; 5,906,202; 5,934,272; 5,960,792; 5,971,951; 6,070,575;6,192,876; 6,230,706; 6,349,719; 6,367,470; 6,543,442; 6,584,971;6,601,581; 4,263,907; 5,709,202; 5,823,179; 6,192,876; 6,644,304;5,549,102; 6,083,922; 6,161,536; 6,264,922; 6,557,549; and 6,612,303 allof which are hereby incorporated by reference in their entirety.

Any known inhalation nebulizer suitable to provide delivery of amedicament as described herein may be used in the various embodimentsand methods described herein. Such nebulizers include, e.g., jetnebulizers, ultrasonic nebulizers, pulsating membrane nebulizers,nebulizers with a vibrating mesh or plate with multiple apertures, andnebulizers comprising a vibration generator and an aqueous chamber(e.g., Pari eFlow®). Commercially available nebulizers suitable for usein the present invention can include the Aeroneb®, MicroAir®, Aeroneb®Pro, and Aeroneb® Go, Aeroneb® Solo, Aeroneb® Solo/Idehaler combination,Aeroneb® Solo or Go Idehaler-Pocket® combination, PARI LC-Plus®, PARILC-Star®, PARI Sprint®, eFlow and eFlow Rapid®, Pari Boy® N and PariDuraneb® (PARI, GmbH), MicroAir® (Omron Healthcare, Inc.), Halolite®(Profile Therapeutics Inc.), Respimat® (Boehringer Ingelheim), Aerodose®(Aerogen, Inc, Mountain View, Calif.), Omron Elite® (Omron Healthcare,Inc.), Omron Microair® (Omron Healthcare, Inc.), Mabismist II® (MabisHealthcare, Inc.), Lumiscope® 6610, (The Lumiscope Company, Inc.),Airsep Mystique®, (AirSep Corporation), Acorn-1 and Acorn-II (VitalSigns, Inc.), Aquatower® (Medical Industries America), Ava-Neb® (HudsonRespiratory Care Incorporated), Cirrus® (Intersurgical Incorporated),Dart® (Professional Medical Products), Devilbiss® Pulmo Aide (DeVilbissCorp.), Downdraft® (Marquest), Fan Jet® (Marquest), MB-5 (Mefar), MistyNeb® (Baxter), Salter 8900 (Salter Labs), Sidestream® (Medic-Aid),Updraft-II® (Hudson Respiratory Care), Whisper Jet® (Marquest MedicalProducts), Aiolos® (Aiolos Medicnnsk Teknik), Inspiron® (IntertechResources, Inc.), Optimist® (Unomedical Inc.), Prodomo®, Spira®(Respiratory Care Center), AERx® and AERx Essence™ (Aradigm), RespirgardII®, Sonik® LDI Nebulizer (Evit Labs), Swirler W Radioaerosol System(AMICI, Inc.), Maquet SUN 145 ultrasonic, Schill untrasonic, compare andcompare Elite from Omron, Monoghan AeroEclipse BAN, Transneb, DeVilbiss800, AerovectRx, Porta-Neb®, Freeway Freedom™, Sidestream, Ventstreamand I-neb produced by Philips, Inc. By further non-limiting example,U.S. Pat. No. 6,196,219, is hereby incorporated by reference in itsentirety.

Any of these and other known nebulizers suitable to provide delivery ofa aqueous inhalation medicament as described herein may be used in thevarious embodiments and methods described herein. In some embodiments,the nebulizers are available from, e.g., Pari GmbH (Starnberg, Germany),DeVilbiss Healthcare (Heston, Middlesex, UK), Healthdyne, Vital Signs,Baxter, Allied Health Care, Invacare, Hudson, Omron, Bremed, AirSep,Luminscope, Medisana, Siemens, Aerogen, Mountain Medical, AerosolMedical Ltd. (Colchester, Essex, UK), AFP Medical (Rugby, Warwickshire,UK), Bard Ltd. (Sunderland, UK), Carri-Med Ltd. (Dorking, UK), PlaemNuiva (Brescia, Italy), Henleys Medical Supplies (London, UK),Intersurgical (Berkshire, UK), Lifecare Hospital Supplies (Leies, UK),Medic-Aid Ltd. (West Sussex, UK), Medix Ltd. (Essex, UK), SinclairMedical Ltd. (Surrey, UK), and many others.

Other nebulizers suitable for use in the methods and systems describeherein can include, but are not limited to, jet nebulizers (optionallysold with compressors), ultrasonic nebulizers, and others. Exemplary jetnebulizers for use herein can include Pari LC plus/ProNeb, Pari LCplus/ProNeb Turbo, Pari LCPlus/Dura Neb 1000 & 2000 Pari LCplus/Walkhaler, Pari LC plus/Pari Master, Pari LC star, Omron CompAir XLPortable Nebulizer System (NE-C18 and JetAir Disposable nebulizer),Omron compare Elite Compressor Nebulizer System (NE-C21 and Elite AirReusable Nebulizer, Pari LC Plus or Pari LC Star nebulizer with PronebUltra compressor, Pulomo-aide, Pulmo-aide LT, Pulmo-aide traveler,Invacare Passport, Inspiration Healthdyne 626, Pulmo-Neb Traveler,DeVilbiss 646, Whisper Jet, AcornII, Misty-Neb, Allied aerosol, SchucoHome Care, Lexan Plasic Pocet Neb, SideStream Hand Held Neb, Mobil Mist,Up-Draft, Up-DraftII, T Up-Draft, ISO-NEB, Ava-Neb, Micro Mist, andPulmoMate.

Exemplary ultrasonic nebulizers suitable to provide delivery of amedicament as described herein can include MicroAir, UltraAir, SiemensUltra Nebulizer 145, CompAir, Pulmosonic, Scout, 5003 Ultrasonic Neb,5110 Ultrasonic Neb, 5004 Desk Ultrasonic Nebulizer, MystiqueUltrasonic, Lumiscope's Ultrasonic Nebulizer, Medisana UltrasonicNebulizer, Microstat Ultrasonic Nebulizer, and Mabismist Hand HeldUltrasonic Nebulizer. Other nebulizers for use herein include 5000Electromagnetic Neb, 5001 Electromagnetic Neb 5002 Rotary Piston Neb,Lumineb I Piston Nebulizer 5500, Aeroneb Portable Nebulizer System,Aerodose Inhaler, and AeroEclipse Breath Actuated Nebulizer. Exemplarynebulizers comprising a vibrating mesh or plate with multiple aperturesare described by R. Dhand in New Nebuliser Technology-Aerosol Generationby Using a Vibrating Mesh or Plate with Multiple Apertures, Long-TermHealthcare Strategies 2003, (July 2003), p. 1-4 and Respiratory Care,47: 1406-1416 (2002), the entire disclosure of each of which is herebyincorporated by reference.

Additional nebulizers suitable for use in the presently describedinvention include nebulizers comprising a vibration generator and anaqueous chamber. Such nebulizers are sold commercially as, e.g., ParieFlow, and are described in U.S. Pat. Nos. 6,962,151, 5,518,179,5,261,601, and 5,152,456, each of which is specifically incorporated byreference herein.

The parameters used in nebulization, such as flow rate, mesh membranesize, aerosol inhalation chamber size, mask size and materials, valves,and power source may be varied as applicable to provide delivery of amedicament as described herein to maximize their use with differenttypes and aqueous inhalation mixtures.

In some embodiments, the drug solution is formed prior to use of thenebulizer by a patient. In other embodiments, the drug is stored in thenebulizer in liquid form, which may include a suspension, solution, orthe like. In other embodiments, the drug is store in the nebulizer insolid form. In this case, the solution is mixed upon activation of thenebulizer, such as described in U.S. Pat. No. 6,427,682 and PCTPublication No. WO 03/035030, both of which are hereby incorporated byreference in their entirety. In these nebulizers, the solid drug,optionally combined with excipients to form a solid composition, isstored in a separate compartment from a liquid solvent.

The liquid solvent is capable of dissolving the solid composition toform a liquid composition, which can be aerosolized and inhaled. Suchcapability is, among other factors, a function of the selected amountand, potentially, the composition of the liquid. To allow easy handlingand reproducible dosing, the sterile aqueous liquid may be able todissolve the solid composition within a short period of time, possiblyunder gentle shaking. In some embodiments, the final liquid is ready touse after no longer than about 30 seconds. In some cases, the solidcomposition is dissolved within about 20 seconds, and advantageously,within about 10 seconds. As used herein, the terms “dissolve(d)”,“dissolving”, and “dissolution” refer to the disintegration of the solidcomposition and the release, i.e., the dissolution, of the activecompound. As a result of dissolving the solid composition with theliquid solvent a liquid composition is formed in which the activecompound is contained in the dissolved state. As used herein, the activecompound is in the dissolved state when at least about 90 wt.-% aredissolved, and more preferably when at least about 95 wt.-% aredissolved.

With regard to basic separated-compartment nebulizer design, itprimarily depends on the specific application whether it is more usefulto accommodate the aqueous liquid and the solid composition withinseparate chambers of the same container or primary package, or whetherthey should be provided in separate containers. If separate containersare used, these are provided as a set within the same secondary package.The use of separate containers is especially preferred for nebulizerscontaining two or more doses of the active compound. There is no limitto the total number of containers provided in a multi-dose kit. In oneembodiment, the solid composition is provided as unit doses withinmultiple containers or within multiple chambers of a container, whereasthe liquid solvent is provided within one chamber or container. In thiscase, a favorable design provides the liquid in a metered-dosedispenser, which may consist of a glass or plastic bottle closed with adispensing device, such as a mechanical pump for metering the liquid.For instance, one actuation of the pumping mechanism may dispense theexact amount of liquid for dissolving one dose unit of the solidcomposition.

In another embodiment for multiple-dose separated-compartmentnebulizers, both the solid composition and the liquid solvent areprovided as matched unit doses within multiple containers or withinmultiple chambers of a container. For instance, two-chambered containerscan be used to hold one unit of the solid composition in one of thechambers and one unit of liquid in the other. As used herein, one unitis defined by the amount of drug present in the solid composition, whichis one unit dose. Such two-chambered containers may, however, also beused advantageously for nebulizers containing only one single drug dose.

In one embodiment of a separated-compartment nebulizer, a blister packhaving two blisters is used, the blisters representing the chambers forcontaining the solid composition and the liquid solvent in matchedquantities for preparing a dose unit of the final liquid composition. Asused herein, a blister pack represents a thermoformed or pressure-formedprimary packaging unit, most likely comprising a polymeric packagingmaterial that optionally includes a metal foil, such as aluminum. Theblister pack may be shaped to allow easy dispensing of the contents. Forinstance, one side of the pack may be tapered or have a tapered portionor region through which the content is dispensable into another vesselupon opening the blister pack at the tapered end. The tapered end mayrepresent a tip.

In some embodiments, the two chambers of the blister pack are connectedby a channel, the channel being adapted to direct fluid from the blistercontaining the liquid solvent to the blister containing the solidcomposition. During storage, the channel is closed with a seal. In thissense, a seal is any structure that prevents the liquid solvent fromcontacting the solid composition. The seal is preferably breakable orremovable; breaking or removing the seal when the nebulizer is to beused will allow the liquid solvent to enter the other chamber anddissolve the solid composition. The dissolution process may be improvedby shaking the blister pack. Thus, the final liquid composition forinhalation is obtained, the liquid being present in one or both of thechambers of the pack connected by the channel, depending on how the packis held.

According to another embodiment, one of the chambers, preferably the onethat is closer to the tapered portion of the blister pack communicateswith a second channel, the channel extending from the chamber to adistal position of the tapered portion. During storage, this secondchannel does not communicate with the outside of the pack but is closedin an air-tight fashion. Optionally, the distal end of the secondchannel is closed by a breakable or removable cap or closure, which maye.g., be a twist-off cap, a break-off cap, or a cut-off cap.

In one embodiment, a vial or container having two compartments is used,the compartment representing the chambers for containing the solidcomposition and the liquid solvent in matched quantities for preparing adose unit of the final liquid composition. The liquid composition and asecond liquid solvent may be contained in matched quantities forpreparing a dose unit of the final liquid composition (by non-limitingexample in cases where two soluble excipients or the pirfenidone orpyridone analog compound and excipient are unstable for storage, yetdesired in the same mixture for administration.

In some embodiments, the two compartments are physically separated butin fluid communication such as when so the vial or container areconnected by a channel or breakable barrier, the channel or breakablebarrier being adapted to direct fluid between the two compartments toenable mixing prior to administration. During storage, the channel isclosed with a seal or the breakable barrier intact. In this sense, aseal is any structure that prevents mixing of contents in the twocompartments. The seal is preferably breakable or removable; breaking orremoving the seal when the nebulizer is to be used will allow the liquidsolvent to enter the other chamber and dissolve the solid composition orin the case of two liquids permit mixing. The dissolution or mixingprocess may be improved by shaking the container. Thus, the final liquidcomposition for inhalation is obtained, the liquid being present in oneor both of the chambers of the pack connected by the channel orbreakable barrier, depending on how the pack is held.

The solid composition itself can be provided in various different typesof dosage forms, depending on the physicochemical properties of thedrug, the desired dissolution rate, cost considerations, and othercriteria. In one of the embodiments, the solid composition is a singleunit. This implies that one unit dose of the drug is comprised in asingle, physically shaped solid form or article. In other words, thesolid composition is coherent, which is in contrast to a multiple unitdosage form, in which the units are incoherent.

Examples of single units which may be used as dosage forms for the solidcomposition include tablets, such as compressed tablets, film-likeunits, foil-like units, wafers, lyophilized matrix units, and the like.In a preferred embodiment, the solid composition is a highly porouslyophilized form. Such lyophilizates, sometimes also called wafers orlyophilized tablets, are particularly useful for their rapiddisintegration, which also enables the rapid dissolution of the activecompound.

On the other hand, for some applications the solid composition may alsobe formed as a multiple unit dosage form as defined above. Examples ofmultiple units are powders, granules, microparticles, pellets, beads,lyophilized powders, and the like. In one embodiment, the solidcomposition is a lyophilized powder. Such a dispersed lyophilized systemcomprises a multitude of powder particles, and due to the lyophilizationprocess used in the formation of the powder, each particle has anirregular, porous microstructure through which the powder is capable ofabsorbing water very rapidly, resulting in quick dissolution.

Another type of multiparticulate system which is also capable ofachieving rapid drug dissolution is that of powders, granules, orpellets from water-soluble excipients which are coated with the drug, sothat the drug is located at the outer surface of the individualparticles. In this type of system, the water-soluble low molecularweight excipient is useful for preparing the cores of such coatedparticles, which can be subsequently coated with a coating compositioncomprising the drug and, preferably, one or more additional excipients,such as a binder, a pore former, a saccharide, a sugar alcohol, afilm-forming polymer, a plasticizer, or other excipients used inpharmaceutical coating compositions.

In another embodiment, the solid composition resembles a coating layerthat is coated on multiple units made of insoluble material. Examples ofinsoluble units include beads made of glass, polymers, metals, andmineral salts. Again, the desired effect is primarily rapiddisintegration of the coating layer and quick drug dissolution, which isachieved by providing the solid composition in a physical form that hasa particularly high surface-to-volume ratio. Typically, the coatingcomposition will, in addition to the drug and the water-soluble lowmolecular weight excipient, comprise one or more excipients, such asthose mentioned above for coating soluble particles, or any otherexcipient known to be useful in pharmaceutical coating compositions.

To achieve the desired effects, it may be useful to incorporate morethan one water-soluble low molecular weight excipient into the solidcomposition. For instance, one excipient may be selected for its drugcarrier and diluent capability, while another excipient may be selectedto adjust the pH. If the final liquid composition needs to be buffered,two excipients that together form a buffer system may be selected.

In one embodiment, the liquid to be used in a separated-compartmentnebulizer is an aqueous liquid, which is herein defined as a liquidwhose major component is water. The liquid does not necessarily consistof water only; however, in one embodiment it is purified water. Inanother embodiment, the liquid contains other components or substances,preferably other liquid components, but possibly also dissolved solids.Liquid components other than water which may be useful include propyleneglycol, glycerol, and polyethylene glycol. One of the reasons toincorporate a solid compound as a solute is that such a compound isdesirable in the final liquid composition, but is incompatible with thesolid composition or with a component thereof, such as the activeingredient.

Another desirable characteristic for the liquid solvent is that it issterile. An aqueous liquid would be subject to the risk of considerablemicrobiological contamination and growth if no measures were taken toensure sterility. In order to provide a substantially sterile liquid, aneffective amount of an acceptable antimicrobial agent or preservativecan be incorporated or the liquid can be sterilized prior to providingit and to seal it with an air-tight seal. In one embodiment, the liquidis a sterilized liquid free of preservatives and provided in anappropriate air-tight container. However, according to anotherembodiment in which the nebulizer contains multiple doses of the activecompound, the liquid may be supplied in a multiple-dose container, suchas a metered-dose dispenser, and may require a preservative to preventmicrobial contamination after the first use.

High Efficiency Liquid Nebulizers

High efficiency liquid nebulizers are inhalation devices that areadapted to deliver a large fraction of a loaded dose to a patient. Somehigh efficiency liquid nebulizers utilize microperforated membranes. Insome embodiments, the high efficiency liquid nebulizer also utilizes oneor more actively or passively vibrating microperforated membranes. Insome embodiments, the high efficiency liquid nebulizer contains one ormore oscillating membranes. In some embodiments, the high efficiencyliquid nebulizer contains a vibrating mesh or plate with multipleapertures and optionally a vibration generator with an aerosol mixingchamber. In some such embodiments, the mixing chamber functions tocollect (or stage) the aerosol from the aerosol generator. In someembodiments, an inhalation valve is also used to allow an inflow ofambient air into the mixing chamber during an inhalation phase and isclosed to prevent escape of the aerosol from the mixing chamber duringan exhalation phase. In some such embodiments, the exhalation valve isarranged at a mouthpiece which is removably mounted at the mixingchamber and through which the patient inhales the aerosol from themixing chamber. In yet some other embodiments, the high efficiencyliquid nebulizer contains a pulsating membrane. In some embodiments, thehigh efficiency liquid nebulizer is continuously operating.

In some embodiments, the high efficiency liquid nebulizer contains avibrating microperforated membrane of tapered nozzles against a bulkliquid will generate a plume of droplets without the need for compressedgas. In these embodiments, a solution in the microperforated membranenebulizer is in contact with a membrane, the opposite side of which isopen to the air. The membrane is perforated by a large number of nozzleorifices of an atomizing head. An aerosol is created when alternatingacoustic pressure in the solution is built up in the vicinity of themembrane causing the fluid on the liquid side of the membrane to beemitted through the nozzles as uniformly sized droplets.

Some embodiments the high efficiency liquid nebulizers use passivenozzle membranes and a separate piezoelectric transducer that are incontact with the solution. In contrast, some high efficiency liquidnebulizers employ an active nozzle membrane, which use the acousticpressure in the nebulizer to generate very fine droplets of solution viathe high frequency vibration of the nozzle membrane.

Some high efficiency liquid nebulizers contain a resonant system. Insome such high efficiency liquid nebulizers, the membrane is driven by afrequency for which the amplitude of the vibrational movement at thecenter of the membrane is particularly large, resulting in a focusedacoustic pressure in the vicinity of the nozzle; the resonant frequencymay be about 100 kHz. A flexible mounting is used to keep unwanted lossof vibrational energy to the mechanical surroundings of the atomizinghead to a minimum. In some embodiments, the vibrating membrane of thehigh efficiency liquid nebulizer may be made of a nickel-palladium alloyby electroforming.

In some embodiments, the high efficiency liquid nebulizer (i) achieveslung deposition of at least about 5%, at least about 6%, at least about7%, at least about 8%, at least about 9%, at least about 10%, at leastabout 15%, at least about 20%, at least about 25%, at least about 30%,at least about 35%, at least about 40%, at least about 45%, at leastabout 50%, at least about 55%, at least about 60%, at least about 65%,at least about 70%, at least about 75%, at least about 80%, or at leastabout 85%, based on the nominal dose of the pirfenidone or pyridoneanalog compound administered to the mammal.

In some embodiments, the high efficiency liquid nebulizer (ii) providesa Geometric Standard Deviation (GSD) of emitted droplet sizedistribution of the solution administered with the high efficiencyliquid nebulizer of about 1.0 μm to about 2.5 μm, about 1.2 μm to about2.5 m, about 1.3 m to about 2.0 m, at least about 1.4 m to about 1.9 μm,at least about 1.5 μm to about 1.9 μm, about 1.5 μm, about 1.7 μm, orabout 1.9 μm.

In some embodiments, the high efficiency liquid nebulizer (iii) providesa mass median aerodynamic diameter (MMAD) of droplet size of thesolution emitted with the high efficiency liquid nebulizer of about 1 μmto about 5 μm, about 2 to about 4 μm, or about 2.5 to about 4.0 μm. Insome embodiments, the high efficiency liquid nebulizer (iii) provides avolumetric mean diameter (VMD) 1 m to about 5 μm, about 2 to about 4 μm,or about 2.5 to about 4.0 μm. In some embodiments, the high efficiencyliquid nebulizer (iii) provides a mass median diameter (MMD) 1 μm toabout 5 μm, about 2 to about 4 μm, or about 2.5 to about 4.0 am.

In some embodiments, the high efficiency liquid nebulizer (iv) providesa fine particle fraction (FPF=% ≤5 microns) of droplets emitted from thehigh efficiency nebulizer of at least about 60%, at least about 65%, atleast about 70%, at least about 75%, at least about 80%, at least about85%, or at least about 90%.

In some embodiments, the high efficiency liquid nebulizer (v) providesan output rate of at least 0.1 mL/min, at least 0.2 mL/min, at least 0.3mL/min, at least 0.4 mL/min, at least 0.5 mL/min, at least 0.6 mL/min,at least 0.8 mL/min, or at least 1.0 mL/min.

In some embodiments, the high efficiency liquid nebulizer (vi) deliversat least about 20%, at least about 25%, at least about 30%, at leastabout 35%, at least about 40%, at least about 45%, at least about 50%,at least about 55%, at least about 60%, at least about 65%, at leastabout 70%, at least about 75%, or at least about 80% of the fill volumeto the mammal.

In some embodiments, the high efficiency liquid nebulizer provides anRDD of at least about 5%, at least about 6%, at least about 7%, at leastabout 8%, at least about 9%, at least about 10%, at least about 15%, atleast about 20%, at least about 25%, at least about 30%, at least about35%, at least about 40%, at least about 45%, at least about 50%, atleast about 55%, at least about 60%, at least about 65%, at least about70%, at least about 75%, at least about 80%, or at least about 85%.

In some embodiments, the high efficiency liquid nebulizer ischaracterized as providing one or more of (i), (ii), (iii) (iv), (v), or(vi). In some embodiments, the high efficiency liquid nebulizer ischaracterized as providing at least one, at least two, at least three,at least four, at least five, or all six of (i), (ii), (iii) (iv), (v),or (vi).

Additional features of a high efficiency liquid nebulizer withperforated membranes are disclosed in U.S. Pat. Nos. 6,962,151,5,152,456, 5,261,601, and 5,518,179, U.S. Pat. No. 6,983,747, each ofwhich is hereby incorporated by reference in its entirety. Otherembodiments of the high efficiency liquid nebulizers containoscillatable membranes. Features of these high efficiency liquidnebulizers are disclosed in 7,252,085; 7,059, 320; 6,983,747, each ofwhich is hereby incorporated by reference in its entirety.

Commercial high efficiency liquid nebulizers are available from: PARI(Germany) under the trade name eFlow®; Nektar Therapeutics (San Carlos,Calif.) under the trade names AeroNeb® Go and AeroNeb® Pro, and AeroNeb®Solo, Respironics (Murrysville, Calif.) under the trade names I-Neb®,Omron (Bannockburn, Ill.) under the trade name Micro-Air®, and Activaero(Germany) under the trade name Akita®. Commercial High EfficiencyNebulizers are also available from Aerogen (Galaway, Ireland) utilizingthe OnQ® nebulizer technology.

Meter Dose Inhaler (MDI)

A propellant driven inhaler (pMDI) releases a metered dose of medicineupon each actuation. The medicine is formulated as a suspension orsolution of a drug substance in a suitable propellant such as ahalogenated hydrocarbon. pMDIs are described in, for example, Newman, S.P., Aerosols and the Lung, Clarke et al., eds., pp. 197-224(Butterworths, London, England, 1984).

In some embodiments, the particle size of the drug substance in an MDImay be optimally chosen. In some embodiments, the particles of activeingredient have diameters of less than about 50 microns. In someembodiments, the particles have diameters of less than about 10 microns.In some embodiments, the particles have diameters of from about 1 micronto about 5 microns. In some embodiments, the particles have diameters ofless than about 1 micron. In one advantageous embodiment, the particleshave diameters of from about 2 microns to about 5 microns.

By non-limiting example, metered-dose inhalers (MDI), the pirfenidone orpyridone analog compound disclosed herein are prepared in dosages todeliver from about 34 mcg to about 463 mg from a formulation meeting therequirements of the MDI. The pirfenidone or pyridone analog compounddisclosed herein may be soluble in the propellant, soluble in thepropellant plus a co-solvent (by non-limiting example ethanol), solublein the propellant plus an additional moiety promoting increasedsolubility (by non-limiting example glycerol or phospholipid), or as astable suspension or micronized, spray-dried or nanosuspension.

By non-limiting example, a metered-dose pirfenidone or pyridone analogcompound may be administered in the described respirable delivered dosein 10 or fewer inhalation breaths, more preferably in 8 or fewerinhalation breaths, more preferably in 6 or fewer inhalation breaths,more preferably in 8 or fewer inhalation breaths, more preferably in 4or fewer inhalation breaths, more preferably in 2 or fewer inhalationbreaths.

The propellants for use with the MDIs may be any propellants known inthe art. Examples of propellants include chlorofluorocarbons (CFCs) suchas dichlorodifluoromethane, trichlorofluorometbane, anddichlorotetrafluoroethane; hydrofluoroalkanes (HFAs); and carbondioxide. It may be advantageous to use HFAs instead of CFCs due to theenvironmental concerns associated with the use of CFCs. Examples ofmedicinal aerosol preparations containing HFAs are presented in U.S.Pat. Nos. 6,585,958; 2,868,691 and 3,014,844, all of which are herebyincorporated by reference in their entirety. In some embodiments, aco-solvent is mixed with the propellant to facilitate dissolution orsuspension of the drug substance.

In some embodiments, the propellant and active ingredient are containedin separate containers, such as described in U.S. Pat. No. 4,534,345,which is hereby incorporated by reference in its entirety.

In some embodiments, the MDI used herein is activated by a patientpushing a lever, button, or other actuator. In other embodiments, therelease of the aerosol is breath activated such that, after initiallyarming the unit, the active compound aerosol is released once thepatient begins to inhale, such as described in U.S. Pat. Nos. 6,672,304;5,404,871; 5,347,998; 5,284,133; 5,217,004; 5,119,806; 5,060,643;4,664,107; 4,648,393; 3,789,843; 3,732,864; 3,636,949; 3,598,294;3,565,070; 3,456,646; 3,456,645; and 3,456,644, each of which is herebyincorporated by reference in its entirety. Such a system enables more ofthe active compound to get into the lungs of the patient. Anothermechanism to help a patient get adequate dosage with the activeingredient may include a valve mechanism that allows a patient to usemore than one breath to inhale the drug, such as described in U.S. Pat.Nos. 4,470,412 and 5,385,140, both of which are hereby incorporated byreference in their entirety.

Additional examples of MDIs known in the art and suitable for use hereininclude U.S. Pat. Nos. 6,435,177; 6,585,958; 5,642,730; 6,223,746;4,955,371; 5,404,871; 5,364,838; and 6,523,536, all of which are herebyincorporated by reference in their entirety.

Dry Powder Inhaler (DPI)

There are two major designs of dry powder inhalers. One design is themetering device in which a reservoir for the drug is placed within thedevice and the patient adds a dose of the drug into the inhalationchamber. The second is a factory-metered device in which each individualdose has been manufactured in a separate container. Both systems dependupon the formulation of drug into small particles of mass mediandiameters from about 1 to about 5 micron, and usually involveco-formulation with larger excipient particles (typically 100 microndiameter lactose particles). Drug powder is placed into the inhalationchamber (either by device metering or by breakage of a factory-metereddosage) and the inspiratory flow of the patient accelerates the powderout of the device and into the oral cavity. Non-laminar flowcharacteristics of the powder path cause the excipient-drug aggregatesto decompose, and the mass of the large excipient particles causes theirimpaction at the back of the throat, while the smaller drug particlesare deposited deep in the lungs.

As with liquid nebulization and MDIs, particle size of the pirfenidoneor pyridone analog compound aerosol formulation may be optimized. If theparticle size is larger than about 5 micron MMAD then the particles aredeposited in upper airways. If the particle size of the aerosol issmaller than about 1 micron then it is delivered into the alveoli andmay get transferred into the systemic blood circulation.

By non-limiting example, in dry powder inhalers, the pirfenidone orpyridone analog compound disclosed herein are prepared in dosages todisperse and deliver from about 34 mcg to about 463 mg from a dry powderformulation.

By non-limiting example, a dry powder pirfenidone or pyridone analogcompound may be administered in the described respirable delivered dosein 10 or fewer inhalation breaths, more preferably in 8 or fewerinhalation breaths, more preferably in 6 or fewer inhalation breaths,more preferably in 8 or fewer inhalation breaths, more preferably in 4or fewer inhalation breaths, more preferably in 2 or fewer inhalationbreaths.

In some embodiments, a dry powder inhaler (DPI) is used to dispense thepirfenidone or pyridone analog compound described herein. DPIs containthe drug substance in fine dry particle form. Typically, inhalation by apatient causes the dry particles to form an aerosol cloud that is drawninto the patient's lungs. The fine dry drug particles may be produced byany technique known in the art. Some well-known techniques include useof a jet mill or other comminution equipment, precipitation fromsaturated or super saturated solutions, spray drying, in situmicronization (Hovione), or supercritical fluid methods. Typical powderformulations include production of spherical pellets or adhesivemixtures. In adhesive mixtures, the drug particles are attached tolarger carrier particles, such as lactose monohydrate of size about 50to about 100 microns in diameter. The larger carrier particles increasethe aerodynamic forces on the carrier/drug agglomerates to improveaerosol formation. Turbulence and/or mechanical devices break theagglomerates into their constituent parts. The smaller drug particlesare then drawn into the lungs while the larger carrier particles depositin the mouth or throat. Some examples of adhesive mixtures are describedin U.S. Pat. No. 5,478,578 and PCT Publication Nos. WO 95/11666, WO87/05213, WO 96/23485, and WO 97/03649, all of which are incorporated byreference in their entirety. Additional excipients may also be includedwith the drug substance.

There are three common types of DPIs, all of which may be used with thepirfenidone or pyridone analog compounds described herein. In asingle-dose DPI, a capsule containing one dose of dry drugsubstance/excipients is loaded into the inhaler. Upon activation, thecapsule is breached, allowing the dry powder to be dispersed and inhaledusing a dry powder inhaler. To dispense additional doses, the oldcapsule must be removed and an additional capsule loaded. Examples ofsingle-dose DPIs are described in U.S. Pat. Nos. 3,807,400; 3,906,950;3,991,761; and 4,013,075, all of which are hereby incorporated byreference in their entirety. In a multiple unit dose DPI, a packagecontaining multiple single dose compartments is provided. For example,the package may comprise a blister pack, where each blister compartmentcontains one dose. Each dose can be dispensed upon breach of a blistercompartment. Any of several arrangements of compartments in the packagecan be used. For example, rotary or strip arrangements are common.Examples of multiple unit does DPIs are described in EPO PatentApplication Publication Nos. 0211595A2, 0455463A1, and 0467172A1, all ofwhich are hereby incorporated by reference in their entirety. In amulti-dose DPI, a single reservoir of dry powder is used. Mechanisms areprovided that measure out single dose amounts from the reservoir to beaerosolized and inhaled, such as described in U.S. Pat. Nos. 5,829,434;5,437,270; 2,587,215; 5,113,855; 5,840,279; 4,688,218; 4,667,668;5,033,463; and 4,805,811 and PCT Publication No. WO 92/09322, all ofwhich are hereby incorporated by reference in their entirety.

In some embodiments, auxiliary energy in addition to or other than apatient's inhalation may be provided to facilitate operation of a DPI.For example, pressurized air may be provided to aid in powderde-agglomeration, such as described in U.S. Pat. Nos. 3,906,950;5,113,855; 5,388,572; 6,029,662 and PCT Publication Nos. WO 93/12831, WO90/07351, and WO 99/62495, all of which are hereby incorporated byreference in their entirety. Electrically driven impellers may also beprovided, such as described in U.S. Pat. Nos. 3,948,264; 3,971,377;4,147,166; 6,006,747 and PCT Publication No. WO 98/03217, all of whichare hereby incorporated by reference in their entirety. Anothermechanism is an electrically powered tapping piston, such as describedin PCT Publication No. WO 90/13327, which is hereby incorporated byreference in its entirety. Other DPIs use a vibrator, such as describedin U.S. Pat. Nos. 5,694,920 and 6,026,809, both of which are herebyincorporated by reference in their entirety. Finally, a scraper systemmay be employed, such as described in PCT Publication No. WO 93/24165,which is hereby incorporated by reference in its entirety.

Additional examples of DPIs for use herein are described in U.S. Pat.Nos. 4,811,731; 5,113,855; 5,840,279; 3,507,277; 3,669,113; 3,635,219;3,991,761; 4,353,365; 4,889,144, 4,907,538; 5,829,434; 6,681,768;6,561,186; 5,918,594; 6,003,512; 5,775,320; 5,740,794; and 6,626,173,all of which are hereby incorporated by reference in their entirety.

In some embodiments, a spacer or chamber may be used with any of theinhalers described herein to increase the amount of drug substance thatgets absorbed by the patient, such as is described in U.S. Pat. Nos.4,470,412; 4,790,305; 4,926,852; 5,012,803; 5,040,527; 5,024,467;5,816,240; 5,027,806; and 6,026,807, all of which are herebyincorporated by reference in their entirety. For example, a spacer maydelay the time from aerosol production to the time when the aerosolenters a patient's mouth. Such a delay may improve synchronizationbetween the patient's inhalation and the aerosol production. A mask mayalso be incorporated for infants or other patients that have difficultyusing the traditional mouthpiece, such as is described in U.S. Pat. Nos.4,809,692; 4,832,015; 5,012,804; 5,427,089; 5,645,049; and 5,988,160,all of which are hereby incorporated by reference in their entirety.

Dry powder inhalers (DPIs), which involve deaggregation andaerosolization of dry powder particles, normally rely upon a burst ofinspired air that is drawn through the unit to deliver a drug dosage.Such devices are described in, for example, U.S. Pat. No. 4,807,814,which is directed to a pneumatic powder ejector having a suction stageand an injection stage; SU 628930 (Abstract), describing a hand-heldpowder disperser having an axial air flow tube; Fox et al., Powder andBulk Engineering, pages 33-36 (March 1988), describing a venturi eductorhaving an axial air inlet tube upstream of a venturi restriction; EP 347779, describing a hand-held powder disperser having a collapsibleexpansion chamber, and U.S. Pat. No. 5,785,049, directed to dry powderdelivery devices for drugs.

Commercial examples of dry powder inhalers that can be used with thepirfenidone or pyridone analog compound formulations described hereininclude the Aerolizer, Turohaler, Handihaler and Discus.

Solution/Dispersion Formulations

In one embodiment, aqueous formulations containing soluble ornanoparticulate drug particles are provided. For aqueous aerosolformulations, the drug may be present at a concentration from about 34mcg/mL to about 463 mg/mL. In some embodiments the drug is present at aconcentration from about 1 mg/mL to about 463 mg/mL, or about 1 mg/mL toabout 400 mg/mL, or about 0.1 mg/mL to about 360 mg/mL, or about 1 mg/mLto about 300 mg/mL, or about 1 mg/mL to about 200 mg/mL, about 1 mg/mLto about 100 mg/mL, or about 1 mg/mL to about 50 mg/mL, or about 5 mg/mLto about 50 mg/mL, or about 10 mg/mL to about 50 mg/mL, or about 15mg/mL to about 50 mg/mL, or about 20 mg/mL to about 50 mg/mL. Suchformulations provide effective delivery to appropriate areas of thelung, with the more concentrated aerosol formulations having theadditional advantage of enabling large quantities of drug substance tobe delivered to the lung in a very short period of time. In oneembodiment, a formulation is optimized to provide a well toleratedformulation. Accordingly, in one embodiment, pirfenidone or pyridoneanalog compound disclosed herein are formulated to have good taste, pHfrom about 4.0 to about 8.0, osmolarity from about 100 to about 5000mOsmol/kg. In some embodiments, the osmolarity is from about 100 toabout 1000 mOsmol/kg. In some embodiments, the osmolarity is from about200 to about 500 mOsmol/kg. In some embodiments, the permeant ionconcentration is from about 30 to about 300 mM.

In some embodiments, described herein is an aqueous pharmaceuticalcomposition comprising pirfenidone or pyridone analog compound, waterand one or more additional ingredients selected from co-solvents,tonicity agents, sweeteners, surfactants, wetting agents, chelatingagents, anti-oxidants, salts, and buffers. It should be understood thatmany excipients may serve several functions, even within the sameformulation.

In some embodiments, pharmaceutical compositions described herein do notinclude any thickening agents.

In some embodiments, the concentration of pirfenidone or pyridone analogcompound in the aqueous pharmaceutical composition is between about 0.1mg/mL and about 100 mg/mL. In some embodiments, the concentration ofpirfenidone or pyridone analog compound in the pharmaceuticalcomposition is between about 1 mg/mL and about 100 mg/mL, between about10 mg/mL and about 100 mg/mL between about 20 mg/mL and about 100 mg/mL,between about 25 mg/mL and about 100 mg/mL, between about 30 mg/mL andabout 100 mg/mL, between about 15 mg/mL and about 50 mg/mL, betweenabout 20 mg/mL and about 50 mg/mL, between about 25 mg/mL and about 50mg/mL, or between about 30 mg/mL and about 50 mg/mL.

In some embodiments, the pH is between about pH 4.0 and about pH 8.0. Insome embodiments, the pH is between about pH 5.0 and about pH 8.0. Insome embodiments, the pH is between about pH 6.0 and about pH 8.0. Insome embodiments, the pH is between about pH 6.5 and about pH 8.0.

In some embodiments, the aqueous pharmaceutical composition includes oneor more co-solvents. In some embodiments, the aqueous pharmaceuticalcomposition includes one or more co-solvents, where the total amount ofco-solvents is from about 1% to about 50% v/v of the total volume of thecomposition. In some embodiments, the aqueous pharmaceutical compositionincludes one or more co-solvents, where the total amount of co-solventsis from about 1% to about 50% v/v, from about 1% to about 40% v/v, fromabout 1% to about 30% v/v, or from about 1% to about 25% v/v, of thetotal volume of the composition. Co-solvents include, but are notlimited to, ethanol, propylene glycol and glycerol. In some embodiments,the aqueous pharmaceutical composition includes ethanol at about 1% v/vto about 25%. In some embodiments, the aqueous pharmaceuticalcomposition includes ethanol at about 1% v/v to about 15%. In someembodiments, the aqueous pharmaceutical composition includes ethanol atabout 1% v/v, 2% v/v, 3% v/v, 4% v/v, 5% v/v, 6% v/v, 7% v/v, 8% v/v, 9%v/v, 10% v/v, 11% v/v, 12% v/v, 13% v/v, 14% v/v, 15% v/v, 16% v/v, 17%v/v, 18% v/v, 19% v/v, 20% v/v, 21% v/v, 22% v/v, 23% v/v, 24% v/v, or25% v/v. In some embodiments, the aqueous pharmaceutical compositionincludes glycerol at about 1% v/v to about 25%. In some embodiments, theaqueous pharmaceutical composition includes glycerol at about 1% v/v toabout 15%. In some embodiments, the aqueous pharmaceutical compositionincludes glycerol at about 1% v/v, 2% v/v, 3% v/v, 4% v/v, 5% v/v, 6%v/v, 7% v/v, 8% v/v, 9% v/v, 10% v/v, 11% v/v, 12% v/v, 13% v/v, 14%v/v, 15% v/v, 16% v/v, 17% v/v, 18% v/v, 19% v/v, 20% v/v, 21% v/v, 22%v/v, 23% v/v, 24% v/v, or 25% v/v. In some embodiments, the aqueouspharmaceutical composition includes propylene glycol at about 1% v/v toabout 50%. In some embodiments, the aqueous pharmaceutical compositionincludes propylene glycol at about 1% v/v to about 25%. In someembodiments, the aqueous pharmaceutical composition includes propyleneglycol at about 1% v/v, 2% v/v, 3% v/v, 4% v/v, 5% v/v, 6% v/v, 7% v/v,8% v/v, 9% v/v, 10% v/v, 11% v/v, 12% v/v, 13% v/v, 14% v/v, 15% v/v,16% v/v, 17% v/v, 18% v/v, 19% v/v, 20% v/v, 21% v/v, 22% v/v, 23% v/v,24% v/v, or 25% v/v.

In some embodiments, the aqueous pharmaceutical composition includesethanol at about 1% v/v to about 25% and propylene glycol at about 1%v/v to about 50%. In some embodiments, the aqueous pharmaceuticalcomposition includes ethanol at about 1% v/v to about 15% and propyleneglycol at about 1% v/v to about 30%. In some embodiments, the aqueouspharmaceutical composition includes ethanol at about 1% v/v to about 8%and propylene glycol at about 1% v/v to about 16%. In some embodiments,the aqueous pharmaceutical composition includes ethanol and twice asmuch propylene glycol, based on volume.

In some embodiments, the aqueous pharmaceutical composition includes abuffer. In some embodiments, the buffer is a citrate buffer or aphosphate buffer. In some embodiments, the buffer is a citrate buffer.In some embodiments, the buffer is a phosphate buffer.

In some embodiments, the aqueous pharmaceutical composition consistsessentially of pirfenidone or pyridone analog compound, water, ethanoland/or propylene glycol, a buffer to maintain the pH at about 4 to 8 andoptionally one or more ingredients selected from salts, surfactants, andsweeteners (taste-masking agents). In some embodiments, the one or moresalts are selected from tonicity agents. In some embodiments, the one ormore salts are selected from sodium chloride and magnesium chloride.

In some embodiments, the aqueous pharmaceutical composition consistsessentially of pirfenidone or pyridone analog compound at aconcentration of about 10 mg/mL to about 50 mg/mL, water, one or twocosolvents (ethanol at a concentration of about 1% v/v to about 25% v/vand/or propylene glycol at a concentration of about 1% v/v to about 50%v/v), a buffer to maintain the pH at about 4 to 8 and optionally one ormore ingredients selected from salts, surfactants, and sweeteners(taste-masking agents).

In one embodiment, the solution or diluent used for preparation ofaerosol formulations has a pH range from about 4.0 to about 8.0. This pHrange improves tolerability. When the aerosol is either acidic or basic,it can cause bronchospasm and cough. Although the safe range of pH isrelative and some patients may tolerate a mildly acidic aerosol, whileothers will experience bronchospasm. Any aerosol with a pH of less thanabout 4.0 typically induces bronchospasm. Aerosols having pH greaterthan about 8.0 may have low tolerability because body tissues aregenerally unable to buffer alkaline aerosols. Aerosols with controlledpH below about 4.0 and over about 8.0 typically result in lungirritation accompanied by severe bronchospasm cough and inflammatoryreactions. For these reasons as well as for the avoidance ofbronchospasm, cough or inflammation in patients, the optimum pH for theaerosol formulation was determined to be between about pH 4.0 to aboutpH 8.0.

By non-limiting example, compositions may also include a buffer or a pHadjusting agent, typically a salt prepared from an organic acid or base.Representative buffers include organic acid salts of citric acid,ascorbic acid, gluconic acid, carbonic acid, tartaric acid, succinicacid, acetic acid, or phthalic acid, Tris, tromethamine, hydrochloride,or phosphate buffers.

Many patients have increased sensitivity to various chemical tastes,including bitter, salt, sweet, metallic sensations. To createwell-tolerated drug products, by non-limiting example taste masking maybe accomplished through the addition of taste-masking excipients,adjusted osmolality, and sweeteners.

Many patients have increased sensitivity to various chemical agents andhave high incidence of bronchospastic, asthmatic or other coughingincidents. Their airways are particularly sensitive to hypotonic orhypertonic and acidic or alkaline conditions and to the presence of anypermanent ion, such as chloride. Any imbalance in these conditions or apresence of chloride above certain value leads to bronchospastic orinflammatory events and/or cough which greatly impair treatment withinhalable formulations. Both these conditions prevent efficient deliveryof aerosolized drugs into the endobronchial space.

In some embodiments, the osmolality of aqueous solutions of thepirfenidone or pyridone analog compound disclosed herein are adjusted byproviding excipients. In some cases, a certain amount of chloride oranother anion is needed for successful and efficacious delivery ofaerosolized pirfenidone or pyridone analog compound.

In some embodiments, the osmolality of aqueous solutions of thepirfenidone or pyridone analog compound disclosed herein is greater than100 mOsmol/kg. In some embodiments, the osmolality of aqueous solutionsof the pirfenidone or pyridone analog compound disclosed herein isgreater than 300 mOsmol/kg. In some embodiments, the osmolality ofaqueous solutions of the pirfenidone or pyridone analog compounddisclosed herein is greater than 1000 mOsmol/kg. In some embodiments,aerosol delivery of aqueous solutions with high osmolality (i.e. greaterthan about 300 mOsmol/kg) have high incidence of bronchospastic,asthmatic or other coughing incidents. In some embodiments, aerosoldelivery of the aqueous solutions having high osmolality (i.e. greaterthan about 300 mOsmol/kg) as described do not increase the incidence ofbronchospastic, asthmatic or other coughing incidents.

In some embodiments, the osmolality of aqueous solutions of thepirfenidone or pyridone analog compound disclosed herein are greaterthan 100 mOsmol/kg above by providing excipients. In some cases, acertain amount of chloride or another anion is needed for successful andefficacious delivery of aerosolized pirfenidone or pyridone analogcompound

In some embodiments, the formulation for an aerosol pirfenidone orpyridone analog compound may comprise from about 34 mcg to about 463 mgpirfenidone or pyridone analog compound per about 1 to about 5 ml ofdilute saline (between 1/10 to 2/1 normal saline). Accordingly, theconcentration of a pirfenidone or pyridone analog compound solution maybe greater than about 34 mcg/ml, greater than about 463 mcg/ml, greaterthan about 1 mg/ml, greater than about 2 mg/mL, greater than about 3.0mg/mL, greater than about 3.7 mg/mL, greater than about 10 mg/mL,greater than about 37 mg/mL, greater than about 50 mg/ml, greater thanabout 100 mg/mL, or greater than 463 mg/mL.

In some embodiments, solution osmolality is from about 100 mOsmol/kg toabout 6000 mOsmol/kg. In some embodiments, solution osmolality is fromabout 100 mOsmol/kg to about 5000 mOsmol/kg. In some other embodiments,the solution osmolality is from about 400 mOsmol/kg to about 5000mOsmol/kg.

In one embodiments, permeant ion concentration is from about 25 mM toabout 400 mM. In various other embodiments, permeant ion concentrationis from about 30 mM to about 300 mM; from about 40 mM to about 200 mM;and from about 50 mM to about 150 mM.

Solid Particle Formulations

In some embodiments, solid drug nanoparticles are provided for use ingenerating dry aerosols or for generating nanoparticles in liquidsuspension. Powders comprising nanoparticulate drug can be made byspray-drying aqueous dispersions of a nanoparticulate drug and a surfacemodifier to form a dry powder which consists of aggregated drugnanoparticles. In one embodiment, the aggregates can have a size ofabout 1 to about 2 microns which is suitable for deep lung delivery. Theaggregate particle size can be increased to target alternative deliverysites, such as the upper bronchial region or nasal mucosa by increasingthe concentration of drug in the spray-dried dispersion or by increasingthe droplet size generated by the spray dryer.

Alternatively, an aqueous dispersion of drug and surface modifier cancontain a dissolved diluent such as lactose or mannitol which, whenspray dried, forms respirable diluent particles, each of which containsat least one embedded drug nanoparticle and surface modifier. Thediluent particles with embedded drug can have a particle size of about 1to about 2 microns, suitable for deep lung delivery. In addition, thediluent particle size can be increased to target alternate deliverysites, such as the upper bronchial region or nasal mucosa by increasingthe concentration of dissolved diluent in the aqueous dispersion priorto spray drying, or by increasing the droplet size generated by thespray dryer.

Spray-dried powders can be used in DPIs or pMDIs, either alone orcombined with freeze-dried nanoparticulate powder. In addition,spray-dried powders containing drug nanoparticles can be reconstitutedand used in either jet or ultrasonic nebulizers to generate aqueousdispersions having respirable droplet sizes, where each droplet containsat least one drug nanoparticle. Concentrated nanoparticulate dispersionsmay also be used in these embodiments of the invention.

Nanoparticulate drug dispersions can also be freeze-dried to obtainpowders suitable for nasal or pulmonary delivery. Such powders maycontain aggregated nanoparticulate drug particles having a surfacemodifier. Such aggregates may have sizes within a respirable range,e.g., about 1 to about 5 microns MMAD.

Freeze dried powders of the appropriate particle size can also beobtained by freeze drying aqueous dispersions of drug and surfacemodifier, which additionally contain a dissolved diluent such as lactoseor mannitol. In these instances the freeze dried powders consist ofrespirable particles of diluent, each of which contains at least oneembedded drug nanoparticle.

Freeze-dried powders can be used in DPIs or pMDIs, either alone orcombined with spray-dried nanoparticulate powder. In addition,freeze-dried powders containing drug nanoparticles can be reconstitutedand used in either jet or ultrasonic nebulizers to generate aqueousdispersions that have respirable droplet sizes, where each dropletcontains at least one drug nanoparticle.

One embodiment of the invention is directed to a process and compositionfor propellant-based systems comprising nanoparticulate drug particlesand a surface modifier. Such formulations may be prepared by wet millingthe coarse drug substance and surface modifier in liquid propellant,either at ambient pressure or under high pressure conditions.Alternatively, dry powders containing drug nanoparticles may be preparedby spray-drying or freeze-drying aqueous dispersions of drugnanoparticles and the resultant powders dispersed into suitablepropellants for use in conventional pMDIs. Such nanoparticulate pMDIformulations can be used for either nasal or pulmonary delivery. Forpulmonary administration, such formulations afford increased delivery tothe deep lung regions because of the small (e.g., about 1 to about 2microns MMAD) particle sizes available from these methods. Concentratedaerosol formulations can also be employed in pMDIs.

Another embodiment is directed to dry powders which containnanoparticulate compositions for pulmonary or nasal delivery. Thepowders may consist of respirable aggregates of nanoparticulate drugparticles, or of respirable particles of a diluent which contains atleast one embedded drug nanoparticle. Powders containing nanoparticulatedrug particles can be prepared from aqueous dispersions of nanoparticlesby removing the water via spray-drying or lyophilization (freezedrying). Spray-drying is less time consuming and less expensive thanfreeze-drying, and therefore more cost-effective. However, certaindrugs, such as biologicals benefit from lyophilization rather thanspray-drying in making dry powder formulations.

Conventional micronized drug particles used in dry powder aerosoldelivery having particle diameters of from about 1 to about 5 micronsMMAD are often difficult to meter and disperse in small quantitiesbecause of the electrostatic cohesive forces inherent in such powders.These difficulties can lead to loss of drug substance to the deliverydevice as well as incomplete powder dispersion and sub-optimal deliveryto the lung. Many drug compounds, particularly proteins and peptides,are intended for deep lung delivery and systemic absorption. Since theaverage particle sizes of conventionally prepared dry powders areusually in the range of from about 1 to about 5 microns MMAD, thefraction of material which actually reaches the alveolar region may bequite small. Thus, delivery of micronized dry powders to the lung,especially the alveolar region, is generally very inefficient because ofthe properties of the powders themselves.

The dry powder aerosols which contain nanoparticulate drugs can be madesmaller than comparable micronized drug substance and, therefore, areappropriate for efficient delivery to the deep lung. Moreover,aggregates of nanoparticulate drugs are spherical in geometry and havegood flow properties, thereby aiding in dose metering and deposition ofthe administered composition in the lung or nasal cavities.

Dry nanoparticulate compositions can be used in both DPIs and pMDIs. Asused herein, “dry” refers to a composition having less than about 5%water.

In one embodiment, compositions are provided containing nanoparticleswhich have an effective average particle size of less than about 1000nm, more preferably less than about 400 nm, less than about 300 nm, lessthan about 250 nm, or less than about 200 nm, as measured bylight-scattering methods. By “an effective average particle size of lessthan about 1000 nm” it is meant that at least 50% of the drug particleshave a weight average particle size of less than about 1000 nm whenmeasured by light scattering techniques. Preferably, at least 70% of thedrug particles have an average particle size of less than about 1000 nm,more preferably at least 90% of the drug particles have an averageparticle size of less than about 1000 nm, and even more preferably atleast about 95% of the particles have a weight average particle size ofless than about 1000 nm.

For aqueous aerosol formulations, the nanoparticulate pirfenidone orpyridone analog compound agent may be present at a concentration ofabout 34 mcg/mL up to about 463 mg/mL. For dry powder aerosolformulations, the nanoparticulate agent may be present at aconcentration of about 34 mg/g up to about 463 mg/g, depending on thedesired drug dosage. Concentrated nanoparticulate aerosols, defined ascontaining a nanoparticulate drug at a concentration of about 34 mcg/mLup to about 463 mg/mL for aqueous aerosol formulations, and about 34mg/g up to about 463 mg/g for dry powder aerosol formulations, arespecifically provided. Such formulations provide effective delivery toappropriate areas of the lung or nasal cavities in short administrationtimes, i.e., less than about 3-15 seconds per dose as compared toadministration times of up to 4 to 20 minutes as found in conventionalpulmonary nebulizer therapies.

Nanoparticulate drug compositions for aerosol administration can be madeby, for example, (1) nebulizing a dispersion of a nanoparticulate drug,obtained by either grinding or precipitation; (2) aerosolizing a drypowder of aggregates of nanoparticulate drug and surface modifier (theaerosolized composition may additionally contain a diluent); or (3)aerosolizing a suspension of nanoparticulate drug or drug aggregates ina non-aqueous propellant. The aggregates of nanoparticulate drug andsurface modifier, which may additionally contain a diluent, can be madein a non-pressurized or a pressurized non-aqueous system. Concentratedaerosol formulations may also be made via such methods.

Milling of aqueous drug to obtain nanoparticulate drug may be performedby dispersing drug particles in a liquid dispersion medium and applyingmechanical means in the presence of grinding media to reduce theparticle size of the drug to the desired effective average particlesize. The particles can be reduced in size in the presence of one ormore surface modifiers. Alternatively, the particles can be contactedwith one or more surface modifiers after attrition. Other compounds,such as a diluent, can be added to the drug/surface modifier compositionduring the size reduction process. Dispersions can be manufacturedcontinuously or in a batch mode.

Another method of forming nanoparticle dispersion is bymicroprecipitation. This is a method of preparing stable dispersions ofdrugs in the presence of one or more surface modifiers and one or morecolloid stability enhancing surface active agents free of any tracetoxic solvents or solubilized heavy metal impurities. Such a methodcomprises, for example, (1) dissolving the drug in a suitable solventwith mixing; (2) adding the formulation from step (1) with mixing to asolution comprising at least one surface modifier to form a clearsolution; and (3) precipitating the formulation from step (2) withmixing using an appropriate nonsolvent. The method can be followed byremoval of any formed salt, if present, by dialysis or diafiltration andconcentration of the dispersion by conventional means. The resultantnanoparticulate drug dispersion can be utilized in liquid nebulizers orprocessed to form a dry powder for use in a DPI or pMDI.

In a non-aqueous, non-pressurized milling system, a non-aqueous liquidhaving a vapor pressure of about 1 atm or less at room temperature andin which the drug substance is essentially insoluble may be used as awet milling medium to make a nanoparticulate drug composition. In such aprocess, a slurry of drug and surface modifier may be milled in thenon-aqueous medium to generate nanoparticulate drug particles. Examplesof suitable non-aqueous media include ethanol,trichloromonofluoromethane, (CFC-11), and dichlorotetafluoroethane(CFC-114). An advantage of using CFC-11 is that it can be handled atonly marginally cool room temperatures, whereas CFC-114 requires morecontrolled conditions to avoid evaporation. Upon completion of millingthe liquid medium may be removed and recovered under vacuum or heating,resulting in a dry nanoparticulate composition. The dry composition maythen be filled into a suitable container and charged with a finalpropellant. Exemplary final product propellants, which ideally do notcontain chlorinated hydrocarbons, include HFA-134a (tetrafluoroethane)and HFA-227 (heptafluoropropane). While non-chlorinated propellants maybe preferred for environmental reasons, chlorinated propellants may alsobe used in this embodiment of the invention.

In a non-aqueous, pressurized milling system, a non-aqueous liquidmedium having a vapor pressure significantly greater than 1 atm at roomtemperature may be used in the milling process to make nanoparticulatedrug compositions. If the milling medium is a suitable halogenatedhydrocarbon propellant, the resultant dispersion may be filled directlyinto a suitable pMDI container. Alternately, the milling medium can beremoved and recovered under vacuum or heating to yield a drynanoparticulate composition. This composition can then be filled into anappropriate container and charged with a suitable propellant for use ina pMDI.

Spray drying is a process used to obtain a powder containingnanoparticulate drug particles following particle size reduction of thedrug in a liquid medium. In general, spray-drying may be used when theliquid medium has a vapor pressure of less than about 1 atm at roomtemperature. A spray-dryer is a device which allows for liquidevaporation and drug powder collection. A liquid sample, either asolution or suspension, is fed into a spray nozzle. The nozzle generatesdroplets of the sample within a range of about 20 to about 100 micron indiameter which are then transported by a carrier gas into a dryingchamber. The carrier gas temperature is typically from about 80 to about200° C. The droplets are subjected to rapid liquid evaporation, leavingbehind dry particles which are collected in a special reservoir beneatha cyclone apparatus. Smaller particles in the range down about 1 micronto about 5 microns are also possible.

If the liquid sample consists of an aqueous dispersion of nanoparticlesand surface modifier, the collected product will consist of sphericalaggregates of the nanoparticulate drug particles. If the liquid sampleconsists of an aqueous dispersion of nanoparticles in which an inertdiluent material was dissolved (such as lactose or mannitol), thecollected product will consist of diluent (e.g., lactose or mannitol)particles which contain embedded nanoparticulate drug particles. Thefinal size of the collected product can be controlled and depends on theconcentration of nanoparticulate drug and/or diluent in the liquidsample, as well as the droplet size produced by the spray-dryer nozzle.Collected products may be used in conventional DPIs for pulmonary ornasal delivery, dispersed in propellants for use in pMDIs, or theparticles may be reconstituted in water for use in nebulizers.

In some instances it may be desirable to add an inert carrier to thespray-dried material to improve the metering properties of the finalproduct. This may especially be the case when the spray dried powder isvery small (less than about 5 micron) or when the intended dose isextremely small, whereby dose metering becomes difficult. In general,such carrier particles (also known as bulking agents) are too large tobe delivered to the lung and simply impact the mouth and throat and areswallowed. Such carriers typically consist of sugars such as lactose,mannitol, or trehalose. Other inert materials, including polysaccharidesand cellulosics, may also be useful as carriers.

Spray-dried powders containing nanoparticulate drug particles may usedin conventional DPIs, dispersed in propellants for use in pMDIs, orreconstituted in a liquid medium for use with nebulizers.

For compounds that are denatured or destabilized by heat, such ascompounds having a low melting point (i.e., about 70 to about 150° C.),or for example, biologics, sublimation is preferred over evaporation toobtain a dry powder nanoparticulate drug composition. This is becausesublimation avoids the high process temperatures associated withspray-drying. In addition, sublimation, also known as freeze-drying orlyophilization, can increase the shelf stability of drug compounds,particularly for biological products. Freeze-dried particles can also bereconstituted and used in nebulizers. Aggregates of freeze-driednanoparticulate drug particles can be blended with either dry powderintermediates or used alone in DPIs and pMDIs for either nasal orpulmonary delivery.

Sublimation involves freezing the product and subjecting the sample tostrong vacuum conditions. This allows for the formed ice to betransformed directly from a solid state to a vapor state. Such a processis highly efficient and, therefore, provides greater yields thanspray-drying. The resultant freeze-dried product contains drug andmodifier(s). The drug is typically present in an aggregated state andcan be used for inhalation alone (either pulmonary or nasal), inconjunction with diluent materials (lactose, mannitol, etc.), in DPIs orpMDIs, or reconstituted for use in a nebulizer.

Liposomal Compositions

In some embodiments, pirfenidone or pyridone analog compounds disclosedherein may be formulated into liposome particles, which can then beaerosolized for inhaled delivery. Lipids which are useful in the presentinvention can be any of a variety of lipids including both neutrallipids and charged lipids. Carrier systems having desirable propertiescan be prepared using appropriate combinations of lipids, targetinggroups and circulation enhancers. Additionally, the compositionsprovided herein can be in the form of liposomes or lipid particles,preferably lipid particles. As used herein, the term “lipid particle”refers to a lipid bilayer carrier which “coats” a nucleic acid and haslittle or no aqueous interior. More particularly, the term is used todescribe a self-assembling lipid bilayer carrier in which a portion ofthe interior layer comprises cationic lipids which form ionic bonds orion-pairs with negative charges on the nucleic acid (e.g., a plasmidphosphodiester backbone). The interior layer can also comprise neutralor fusogenic lipids and, in some embodiments, negatively charged lipids.The outer layer of the particle will typically comprise mixtures oflipids oriented in a tail-to-tail fashion (as in liposomes) with thehydrophobic tails of the interior layer. The polar head groups presenton the lipids of the outer layer will form the external surface of theparticle.

Liposomal bioactive agents can be designed to have a sustainedtherapeutic effect or lower toxicity allowing less frequentadministration and an enhanced therapeutic index. Liposomes are composedof bilayers that entrap the desired pharmaceutical. These can beconfigured as multilamellar vesicles of concentric bilayers with thepharmaceutical trapped within either the lipid of the different layersor the aqueous space between the layers.

By non-limiting example, lipids used in the compositions may besynthetic, semi-synthetic or naturally-occurring lipids, includingphospholipids, tocopherols, steroids, fatty acids, glycoproteins such asalbumin, negatively-charged lipids and cationic lipids. Phosholipidsinclude egg phosphatidylcholine (EPC), egg phosphatidylglycerol (EPG),egg phosphatidylinositol (EPI), egg phosphatidylserine (EPS),phosphatidylethanolamine (EPE), and egg phosphatidic acid (EPA); thesoya counterparts, soy phosphatidylcholine (SPC); SPG, SPS, SPI, SPE,and SPA; the hydrogenated egg and soya counterparts (e.g., HEPC, HSPC),other phospholipids made up of ester linkages of fatty acids in the 2and 3 of glycerol positions containing chains of 12 to 26 carbon atomsand different head groups in the 1 position of glycerol that includecholine, glycerol, inositol, serine, ethanolamine, as well as thecorresponding phosphatidic acids. The chains on these fatty acids can besaturated or unsaturated, and the phospholipid can be made up of fattyacids of different chain lengths and different degrees of unsaturation.In particular, the compositions of the formulations can includedipalmitoylphosphatidylcholine (DPPC), a major constituent ofnaturally-occurring lung surfactant as well asdioleoylphosphatidylcholine (DOPC) and dioleoylphosphatidylglycerol(DOPG). Other examples include dimyristoylphosphatidycholine (DMPC) anddimyristoylphosphatidylglycerol (DMPG) dipalmitoylphosphatidcholine(DPPC) and dipalmitoylphosphatidylglycerol (DPPG)distearoylphosphatidylcholine (DSPC) and distearoylphosphatidylglycerol(DSPG), dioleylphosphatidylethanolamine (DOPE) and mixed phospholipidslike palmitoylstearoylphosphatidylcholine (PSPC) andpalmitoylstearoylphosphatidylglycerol (PSPG), and single acylatedphospholipids like mono-oleoyl-phosphatidylethanolamine (MOPE).

In a preferred embodiment, PEG-modified lipids are incorporated into thecompositions of the present invention as the aggregation-preventingagent. The use of a PEG-modified lipid positions bulky PEG groups on thesurface of the liposome or lipid carrier and prevents binding of DNA tothe outside of the carrier (thereby inhibiting cross-linking andaggregation of the lipid carrier). The use of a PEG-ceramide is oftenpreferred and has the additional advantages of stabilizing membranebilayers and lengthening circulation lifetimes. Additionally,PEG-ceramides can be prepared with different lipid tail lengths tocontrol the lifetime of the PEG-ceramide in the lipid bilayer. In thismanner, “programmable” release can be accomplished which results in thecontrol of lipid carrier fusion. For example, PEG-ceramides havingC20-acyl groups attached to the ceramide moiety will diffuse out of alipid bilayer carrier with a half-life of 22 hours. PEG-ceramides havingC14- and C8-acyl groups will diffuse out of the same carrier withhalf-lives of 10 minutes and less than 1 minute, respectively. As aresult, selection of lipid tail length provides a composition in whichthe bilayer becomes destabilized (and thus fusogenic) at a known rate.Though less preferred, other PEG-lipids or lipid-polyoxyethyleneconjugates are useful in the present compositions. Examples of suitablePEG-modified lipids include PEG-modified phosphatidylethanolamine andphosphatidic acid, PEG-modified diacylglycerols and dialkylglycerols,PEG-modified dialkylamines and PEG-modified1,2-diacyloxypropan-3-amines. Particularly preferred are PEG-ceramideconjugates (e.g., PEG-Cer-C8, PEG-Cer-C14 or PEG-Cer-C20) which aredescribed in U.S. Pat. No. 5,820,873, incorporated herein by reference.

The compositions of the present invention can be prepared to provideliposome compositions which are about 50 nm to about 400 nm in diameter.One with skill in the art will understand that the size of thecompositions can be larger or smaller depending upon the volume which isencapsulated. Thus, for larger volumes, the size distribution willtypically be from about 80 nm to about 300 nm.

Surface Modifiers

Pirfenidone or pyridone analog compounds disclosed herein may beprepared in a pharmaceutical composition with suitable surface modifierswhich may be selected from known organic and inorganic pharmaceuticalexcipients. Such excipients include low molecular weight oligomers,polymers, surfactants and natural products. Preferred surface modifiersinclude nonionic and ionic surfactants. Two or more surface modifierscan be used in combination.

Representative examples of surface modifiers include cetyl pyridiniumchloride, gelatin, casein, lecithin (phosphatides), dextran, glycerol,gum acacia, cholesterol, tragacanth, stearic acid, benzalkoniumchloride, calcium stearate, glycerol monostearate, cetostearyl alcohol,cetomacrogol emulsifying wax, sorbitan esters, polyoxyethylene alkylethers (e.g., macrogol ethers such as cetomacrogol 1000),polyoxyethylene castor oil derivatives, polyoxyethylene sorbitan fattyacid esters (e.g., the commercially available Tweens™, such as e.g.,Tween 20™ and Tween 80™, (ICI Specialty Chemicals)); polyethyleneglycols (e.g., Carbowaxs 3350™, and 1450™, and Carbopol 934™, (UnionCarbide)), dodecyl trimethyl ammonium bromide, polyoxyethylenestearates,colloidal silicon dioxide, phosphates, sodium dodecylsulfate,carboxymethylcellulose calcium, hydroxypropyl cellulose (HPC, HPC-SL,and HPC-L), hydroxypropyl methylcellulose (HPMC), carboxymethylcellulosesodium, methylcellulose, hydroxyethylcellulose, hydroxypropylcellulose,hydroxypropylmethyl-cellulose phthalate, noncrystalline cellulose,magnesium aluminum silicate, triethanolamine, polyvinyl alcohol (PVA),polyvinylpyrrolidone (PVP), 4-(1,1,3,3-tetaamethylbutyl)-phenol polymerwith ethylene oxide and formaldehyde (also known as tyloxapol,superione, and triton), poloxamers (e.g., Pluronics F68™, and F108™,which are block copolymers of ethylene oxide and propylene oxide);poloxamnines (e.g., Tetronic 908™, also known as Poloxamine 908™, whichis a tetrafunctional block copolymer derived from sequential addition ofpropylene oxide and ethylene oxide to ethylenediamine (BASF WyandotteCorporation, Parsippany, N.J.)); a charged phospholipid such asdimyristoyl phophatidyl glycerol, dioctylsulfosuccinate (DOSS); Tetronic1508™; (T-1508) (BASF Wyandotte Corporation), dialkylesters of sodiumsulfosuccinic acid (e.g., Aerosol OT™, which is a dioctyl ester ofsodium sulfosuccinic acid (American Cyanamid)); Duponol P™, which is asodium lauryl sulfate (DuPont); Tritons X-200™, which is an alkyl arylpolyether sulfonate (Rohm and Haas); Crodestas F-110™, which is amixture of sucrose stearate and sucrose distearate (Croda Inc.);p-isononylphenoxypoly-(glycidol), also known as Olin-log™, or Surfactant10-G™, (Olin Chemicals, Stamford, Conn.); Crodestas SL-40™, (Croda,Inc.); and SA9OHCO, which is C₁8H₃₇ CH₂ (CON(CH₃)—CH₂ (CHOH)₄ (CH₂ OH)₂(Eastman Kodak Co.); decanoyl-N-methylglucamide; n-decylβ-D-glucopyranoside; n-decyl β-D-maltopyranoside; n-dodecylβ-D-glucopyranoside; n-dodecyl β-D-maltoside;heptanoyl-N-methylglucamide; n-heptyl-β-D-glucopyranoside; n-heptylβ-D-thioglucoside; n-hexyl β-D-glucopyranoside;nonanoyl-N-methylglucamide; n-noyl β-D-glucopyranoside;octanoyl-N-methylglucarmide; n-octyl-β-D-glucopyranoside; octylβ-D-thioglucopyranoside; and the like. Tyloxapol is a particularlypreferred surface modifier for the pulmonary or intranasal delivery ofsteroids, even more so for nebulization therapies.

Examples of surfactants for use in the solutions disclosed hereininclude, but are not limited to, ammonium laureth sulfate, cetamineoxide, cetrimonium chloride, cetyl alcohol, cetyl myristate, cetylpalmitate, cocamide DEA, cocamidopropyl betaine, cocamidopropylamineoxide, cocamide MEA, DEA lauryl sulfate, di-stearyl phthalic acid amide,dicetyl dimethyl ammonium chloride, dipalmitoylethyl hydroxethylmonium,disodium laureth sulfosuccinate, di(hydrogenated) tallow phthalic acid,glyceryl dilaurate, glyceryl distearate, glyceryl oleate, glycerylstearate, isopropyl myristate nf, isopropyl palmitate nf, lauramide DEA,lauramide MEA, lauramide oxide, myristamine oxide, octyl isononanoate,octyl palmitate, octyldodecyl neopentanoate, olealkonium chloride, PEG-2stearate, PEG-32 glyceryl caprylate/caprate, PEG-32 glyceryl stearate,PEG-4 and PEG-150 stearate & distearate, PEG-4 to PEG-150 laurate &dilaurate, PEG-4 to PEG-150 oleate & dioleate, PEG-7 glyceryl cocoate,PEG-8 beeswax, propylene glycol stearate, sodium C14-16 olefinsulfonate, sodium lauryl sulfoacetate, sodium lauryl sulphate, sodiumtrideceth sulfate, stearalkonium chloride, stearamide oxide,TEA-dodecylbenzene sulfonate, TEA lauryl sulfate

Most of these surface modifiers are known pharmaceutical excipients andare described in detail in the Handbook of Pharmaceutical Excipients,published jointly by the American Pharmaceutical Association and ThePharmaceutical Society of Great Britain (The Pharmaceutical Press,1986), specifically incorporated by reference. The surface modifiers arecommercially available and/or can be prepared by techniques known in theart. The relative amount of drug and surface modifier can vary widelyand the optimal amount of the surface modifier can depend upon, forexample, the particular drug and surface modifier selected, the criticalmicelle concentration of the surface modifier if it forms micelles, thehydrophilic-lipophilic-balance (HLB) of the surface modifier, themelting point of the surface modifier, the water solubility of thesurface modifier and/or drug, the surface tension of water solutions ofthe surface modifier, etc.

In the present invention, the optimal ratio of drug to surface modifieris ˜0.1% to ˜99.9% pirfenidone or pyridone analog compound, morepreferably about 10% to about 90%.

Microspheres

Microspheres can be used for pulmonary delivery of pirfenidone orpyridone analog compounds by first adding an appropriate amount of drugcompound to be solubilzed in water. For example, an aqueous pirfenidoneor pyridone analog compound solution may be dispersed in methylenechloride containing a predetermined amount (0.1-1% w/v) ofpoly(DL-lactide-co-glycolide) (PLGA) by probe sonication for 1-3 min onan ice bath. Separately, a pirfenidone or pyridone analog compound maybe solubilized in methylene chloride containing PLGA (0.1-1% w/v). Theresulting water-in-oil primary emulsion or the polymer/drug solutionwill be dispersed in an aqueous continuous phase consisting of 1-2%polyvinyl alcohol (previously cooled to 4° C.) by probe sonication for3-5 min on an ice bath. The resulting emulsion will be stirredcontinuously for 2-4 hours at room temperature to evaporate methylenechloride. Microparticles thus formed will be separated from thecontinuous phase by centrifuging at 8000-10000 rpm for 5-10 min.Sedimented particles will be washed thrice with distilled water andfreeze dried. Freeze-dried pirfenidone or pyridone analog compoundmicroparticles will be stored at −20° C.

By non-limiting example, a spray drying approach will be employed toprepare pirfenidone or pyridone analog compound microspheres. Anappropriate amount of pirfenidone or pyridone analog compound will besolubilized in methylene chloride containing PLGA (0.1-1%). Thissolution will be spray dried to obtain the microspheres.

By non-limiting example, pirfenidone or pyridone analog compoundmicroparticles will be characterized for size distribution (requirement:90% <5 μm, 95% <10 μm), shape, drug loading efficiency and drug releaseusing appropriate techniques and methods.

By non-limiting example, this approach may also be used to sequester andimprove the water solubility of solid, AUC shape-enhancing formulations,such as low-solubility pirfenidone or pyridone analog compounds or saltforms for nanoparticle-based formulations.

A certain amount of pirfenidone or pyridone analog compound can be firstdissolved in the minimal quantity of ethanol 96% necessary to maintainthe fluoroquinolone in solution when diluted with water from 96 to 75%.This solution can then be diluted with water to obtain a 75% ethanolsolution and then a certain amount of paracetamol can be added to obtainthe following w/w drug/polymer ratios: 1:2, 1:1, 2:1, 3:1, 4:1, 6:1,9:1, and 19:1. These final solutions are spray-dried under the followingconditions: feed rate, 15 mL/min; inlet temperature, 110° C.; outlettemperature, 85° C.; pressure 4 bar and throughput of drying air, 35m3/hr. Powder is then collected and stored under vacuum in adessiccator.

Solid Lipid Particles

Preparation of pirfenidone or pyridone analog compound solid lipidparticles may involve dissolving the drug in a lipid melt (phospholipidssuch as phophatidyl choline and phosphatidyl serine) maintained at leastat the melting temperature of the lipid, followed by dispersion of thedrug-containing melt in a hot aqueous surfactant solution (typically1-5% w/v) maintained at least at the melting temperature of the lipid.The coarse dispersion will be homogenized for 1-10 min using aMicrofluidizer® to obtain a nanoemulsion. Cooling the nanoemulsion to atemperature between 4-25° C. will re-solidify the lipid, leading toformation of solid lipid nanoparticles. Optimization of formulationparameters (type of lipid matrix, surfactant concentration andproduction parameters) will be performed so as to achieve a prolongeddrug delivery. By non-limiting example, this approach may also be usedto sequester and improve the water solubility of solid, AUCshape-enhancing formulations, such as low-solubility pirfenidone orpyridone analog compounds or salt forms for nanoparticle-basedformulations.

Melt-Extrusion AUC Shape-Enhancing Formulation

Melt-Extrusion AUC shape-enhancing pirfenidone or pyridone analogcompound formulations may be preparation by dissolving the drugs inmicelles by adding surfactants or preparing micro-emulsion, forminginclusion complexes with other molecules such as cyclodextrins, formingnanoparticles of the drugs, or embedding the amorphous drugs in apolymer matrix. Embedding the drug homogeneously in a polymer matrixproduces a solid dispersion. Solid dispersions can be prepared in twoways: the solvent method and the hot melt method. The solvent methoduses an organic solvent wherein the drug and appropriate polymer aredissolved and then (spray) dried. The major drawbacks of this method arethe use of organic solvents and the batch mode production process. Thehot melt method uses heat in order to disperse or dissolve the drug inan appropriate polymer. The melt-extrusion process is an optimizedversion of the hot melt method. The advantage of the melt-extrusionapproach is lack of organic solvent and continuous production process.As the melt-extrusion is a novel pharmaceutical technique, theliterature dealing with it is limited. The technical set-up involves amixture and extrusion of pirfenidone or pyridone analog compound,hydroxypropyl-b-cyclodextrin (HP-b-CD), and hydroxypropylmethylcellulose(HPMC), in order to, by non-limiting example create a AUCshape-enhancing formulation of pirfenidone or pyridone analog compound.Cyclodextrin is a toroidal-shaped molecule with hydroxyl groups on theouter surface and a cavity in the center. Cyclodextrin sequesters thedrug by forming an inclusion complex. The complex formation betweencyclodextrins and drugs has been investigated extensively. It is knownthat water-soluble polymer interacts with cyclodextrin and drug in thecourse of complex formation to form a stabilized complex of drug andcyclodextrin co-complexed with the polymer. This complex is more stablethan the classic cyclodextrin-drug complex. As one example, HPMC iswater soluble; hence using this polymer with HP-b-CD in the melt isexpected to create an aqueous soluble AUC shape-enhancing formulation.By non-limiting example, this approach may also be used to sequester andimprove the water solubility of solid, AUC shape-enhancing formulations,such as low-solubility pirfenidone or pyridone analog compounds or saltforms for nanoparticle-based formulations.

Co-Precipitates

Co-precipitate pirfenidone or pyridone analog compound formulations maybe prepared by formation of co-precipitates with pharmacologicallyinert, polymeric materials. It has been demonstrated that the formationof molecular solid dispersions or co-precipitates to create an AUCshape-enhancing formulations with various water-soluble polymers cansignificantly slow their in vitro dissolution rates and/or in vivoabsorption. In preparing powdered products, grinding is generally usedfor reducing particle size, since the dissolution rate is stronglyaffected by particle size. Moreover, a strong force (such as grinding)may increase the surface energy and cause distortion of the crystallattice as well as reducing particle size. Co-grinding drug withhydroxypropylmethylcellulose, b-cyclodextrin, chitin and chitosan,crystalline cellulose, and gelatin, may enhance the dissolutionproperties such that AUC shape-enhancement is obtained for otherwisereadily bioavailable pirfenidone or pyridone analog compounds. Bynon-limiting example, this approach may also be used to sequester andimprove the water solubility of solid, AUC shape-enhancing formulations,such as low-solubility pirfenidone or pyridone analog compounds or saltforms for nanoparticle-based formulations.

Dispersion-Enhancing Peptides

Compositions may include one or more di- or tripeptides containing twoor more leucine residues. By further non-limiting example, U.S. Pat. No.6,835,372 disclosing dispersion-enhancing peptides, is herebyincorporated by reference in its entirety. This patent describes thediscovery that di-leucyl-containing dipeptides (e.g., dileucine) andtripeptides are superior in their ability to increase the dispersibilityof powdered composition.

In another embodiment, highly dispersible particles including an aminoacid are administered. Hydrophobic amino acids are preferred. Suitableamino acids include naturally occurring and non-naturally occurringhydrophobic amino acids. Some naturally occurring hydrophobic aminoacids, including but not limited to, non-naturally occurring amino acidsinclude, for example, beta-amino acids. Both D, L and racemicconfigurations of hydrophobic amino acids can be employed. Suitablehydrophobic amino acids can also include amino acid analogs. As usedherein, an amino acid analog includes the D or L configuration of anamino acid having the following formula: —NH—CHR—CO—, wherein R is analiphatic group, a substituted aliphatic group, a benzyl group, asubstituted benzyl group, an aromatic group or a substituted aromaticgroup and wherein R does not correspond to the side chain of anaturally-occurring amino acid. As used herein, aliphatic groups includestraight chained, branched or cyclic C1-C8 hydrocarbons which arecompletely saturated, which contain one or two heteroatoms such asnitrogen, oxygen or sulfur and/or which contain one or more units ofdesaturation. Aromatic groups include carbocyclic aromatic groups suchas phenyl and naphthyl and heterocyclic aromatic groups such asimidazolyl, indolyl, thienyl, furanyl, pyridyl, pyranyl, oxazolyl,benzothienyl, benzofuranyl, quinolinyl, isoquinolinyl and acridintyl.

Suitable substituents on an aliphatic, aromatic or benzyl group include—OH, halogen (—Br, —Cl, —I and —F)—O(aliphatic, substituted aliphatic,benzyl, substituted benzyl, aryl or substituted aryl group), —CN, —NO₂,—COOH, —NH₂, —NH(aliphatic group, substituted aliphatic, benzyl,substituted benzyl, aryl or substituted aryl group), —N(aliphatic group,substituted aliphatic, benzyl, substituted benzyl, aryl or substitutedaryl group)₂, —COO(aliphatic group, substituted aliphatic, benzyl,substituted benzyl, aryl or substituted aryl group), —CONH₂,—CONH(aliphatic, substituted aliphatic group, benzyl, substitutedbenzyl, aryl or substituted aryl group)), —SH, —S(aliphatic, substitutedaliphatic, benzyl, substituted benzyl, aromatic or substituted aromaticgroup) and —NH—C(.dbd.NH)—NH₂. A substituted benzylic or aromatic groupcan also have an aliphatic or substituted aliphatic group as asubstituent. A substituted aliphatic group can also have a benzyl,substituted benzyl, aryl or substituted aryl group as a substituent. Asubstituted aliphatic, substituted aromatic or substituted benzyl groupcan have one or more substituents. Modifying an amino acid substituentcan increase, for example, the lypophilicity or hydrophobicity ofnatural amino acids which are hydrophilic.

A number of the suitable amino acids, amino acids analogs and saltsthereof can be obtained commercially. Others can be synthesized bymethods known in the art.

Hydrophobicity is generally defined with respect to the partition of anamino acid between a nonpolar solvent and water. Hydrophobic amino acidsare those acids which show a preference for the nonpolar solvent.Relative hydrophobicity of amino acids can be expressed on ahydrophobicity scale on which glycine has the value 0.5. On such ascale, amino acids which have a preference for water have values below0.5 and those that have a preference for nonpolar solvents have a valueabove 0.5. As used herein, the term hydrophobic amino acid refers to anamino acid that, on the hydrophobicity scale, has a value greater orequal to 0.5, in other words, has a tendency to partition in thenonpolar acid which is at least equal to that of glycine.

Examples of amino acids which can be employed include, but are notlimited to: glycine, proline, alanine, cysteine, methionine, valine,leucine, tyosine, isoleucine, phenylalanine, tryptophan. Preferredhydrophobic amino acids include leucine, isoleucine, alanine, valine,phenylalanine and glycine. Combinations of hydrophobic amino acids canalso be employed. Furthermore, combinations of hydrophobic andhydrophilic (preferentially partitioning in water) amino acids, wherethe overall combination is hydrophobic, can also be employed.

The amino acid can be present in the particles of the invention in anamount of at least 10 weight %. Preferably, the amino acid can bepresent in the particles in an amount ranging from about 20 to about 80weight %. The salt of a hydrophobic amino acid can be present in theparticles of the invention in an amount of at least 10 weight percent.Preferably, the amino acid salt is present in the particles in an amountranging from about 20 to about 80 weight %. In preferred embodiments theparticles have a tap density of less than about 0.4 g/cm3.

Methods of forming and delivering particles which include an amino acidare described in U.S. Pat. No. 6,586,008, entitled Use of Simple AminoAcids to Form Porous Particles During Spray Drying, the teachings ofwhich are incorporated herein by reference in their entirety.

Proteins/Amino Acids

Protein excipients may include albumins such as human serum albumin(HSA), recombinant human albumin (rHA), gelatin, casein, hemoglobin, andthe like. Suitable amino acids (outside of the dileucyl-peptides of theinvention), which may also function in a buffering capacity, includealanine, glycine, arginine, betaine, histidine, glutamic acid, asparticacid, cysteine, lysine, leucine, isoleucine, valine, methionine,phenylalanine, aspartame, tyrosine, tryptophan, and the like. Preferredare amino acids and polypeptides that function as dispersing agents.Amino acids falling into this category include hydrophobic amino acidssuch as leucine, valine, isoleucine, tryptophan, alanine, methionine,phenylalanine, tyrosine, histidine, and proline.Dispersibility-enhancing peptide excipients include dimers, trimers,tetramers, and pentamers comprising one or more hydrophobic amino acidcomponents such as those described above.

Carbohydrates

By non-limiting example, carbohydrate excipients may includemonosaccharides such as fructose, maltose, galactose, glucose,D-mannose, sorbose, and the like; disaccharides, such as lactose,sucrose, trehalose, cellobiose, and the like; polysaccharides, such asraffinose, melezitose, maltodextrins, dextrans, starches, and the like;and alditols, such as mannitol, xylitol, maltitol, lactitol, xylitolsorbitol (glucitol), pyranosyl sorbitol, myoinositol, isomalt, trehaloseand the like.

Polymers

By non-limiting example, compositions may also include polymericexcipients/additives, e.g., polyvinylpyrrolidones, derivatizedcelluloses such as hydroxymethylcellulose, hydroxyethylcellulose, andhydroxypropylmethylcellulose, Ficolls (a polymeric sugar),hydroxyethylstarch, dextrates (by non-limiting example cyclodextrins mayinclude, 2-hydroxypropyl-beta-cyclodextrin,2-hydroxypropyl-gamma-cyclodextrin, randomly methylatedbeta-cyclodextrin, dimethyl-alpha-cyclodextrin,dimethyl-beta-cyclodextrin, maltosyl-alpha-cyclodextrin,glucosyl-1-alpha-cyclodextrin, glucosyl-2-alpha-cyclodextrin,alpha-cyclodextrin, beta-cyclodextrin, gamma-cyclodextrin, andsulfobutylether-beta-cyclodextrin), polyethylene glycols, and pectin mayalso be used.

Highly dispersible particles administered comprise a bioactive agent anda biocompatible, and preferably biodegradable polymer, copolymer, orblend. The polymers may be tailored to optimize differentcharacteristics of the particle including: i) interactions between theagent to be delivered and the polymer to provide stabilization of theagent and retention of activity upon delivery; ii) rate of polymerdegradation and, thereby, rate of drug release profiles; iii) surfacecharacteristics and targeting capabilities via chemical modification;and iv) particle porosity.

Surface eroding polymers such as polyanhydrides may be used to form theparticles. For example, polyanhydrides such aspoly[(p-carboxyphenoxy)hexane anhydride] (PCPH) may be used.Biodegradable polyanhydrides are described in U.S. Pat. No. 4,857,311.Bulk eroding polymers such as those based on polyesters includingpoly(hydroxy acids) also can be used. For example, polyglycolic acid(PGA), polylactic acid (PLA), or copolymers thereof may be used to formthe particles. The polyester may also have a charged or functionalizablegroup, such as an amino acid. In a preferred embodiment, particles withcontrolled release properties can be formed of poly(D,L-lactic acid)and/or poly(DL-lactic-co-glycolic acid) (“PLGA”) which incorporate asurfactant such as dipalmitoyl phosphatidylcholine (DPPC).

Other polymers include polyamides, polycarbonates, polyalkylenes such aspolyethylene, polypropylene, poly(ethylene glycol), poly(ethyleneoxide), poly(ethylene terephthalate), poly vinyl compounds such aspolyvinyl alcohols, polyvinyl ethers, and polyvinyl esters, polymers ofacrylic and methacrylic acids, celluloses and other polysaccharides, andpeptides or proteins, or copolymers or blends thereof. Polymers may beselected with or modified to have the appropriate stability anddegradation rates in vivo for different controlled drug deliveryapplications.

Highly dispersible particles can be formed from functionalized polyestergraft copolymers, as described in Hrkach et al., Macromolecules, 28:4736-4739 (1995); and Hrkach et al., “Poly(L-Lactic acid-co-amino acid)Graft Copolymers: A Class of Functional Biodegradable Biomaterials” inHydrogels and Biodegradable Polymers for Bioapplications, ACS SymposiumSeries No. 627, Raphael M, Ottenbrite et al., Eds., American ChemicalSociety, Chapter 8, pp. 93-101, 1996.

In a preferred embodiment of the invention, highly dispersible particlesincluding a bioactive agent and a phospholipid are administered.Examples of suitable phospholipids include, among others, phosphatidylcholines, phosphatidylethanolamines, phosphatidylglycerols,phosphatidylserines, phosphatidylinositols and combinations thereof.Specific examples of phospholipids include but are not limited tophosphatidylcholines dipalmitoyl phosphatidylcholine (DPPC), dipalmitoylphosphatidylethanolamine (DPPE), distearoyl phosphatidyicholine (DSPC),dipalmitoyl phosphatidyl glycerol (DPPG) or any combination thereof.Other phospholipids are known to those skilled in the art. In apreferred embodiment, the phospholipids are endogenous to the lung.

The phospholipid, can be present in the particles in an amount rangingfrom about 0 to about 90 weight %. More commonly it can be present inthe particles in an amount ranging from about 10 to about 60 weight %.

In another embodiment of the invention, the phospholipids orcombinations thereof are selected to impart controlled releaseproperties to the highly dispersible particles. The phase transitiontemperature of a specific phospholipid can be below, about or above thephysiological body temperature of a patient. Preferred phase transitiontemperatures range from 30 degrees C. to 50 degrees C. (e.g., within+/−10 degrees of the normal body temperature of patient). By selectingphospholipids or combinations of phospholipids according to their phasetransition temperature, the particles can be tailored to have controlledrelease properties. For example, by administering particles whichinclude a phospholipid or combination of phospholipids which have aphase transition temperature higher than the patient's body temperature,the release of dopamine precursor, agonist or any combination ofprecursors and/or agonists can be slowed down. On the other hand, rapidrelease can be obtained by including in the particles phospholipidshaving lower transition temperatures.

Taste Masking, Flavor, Other

As also described above, pirfenidone or pyridone analog compoundformulations disclosed herein and related compositions, may furtherinclude one or more taste-masking agents such as flavoring agents,inorganic salts (e.g., sodium chloride), sweeteners, antioxidants,antistatic agents, surfactants (e.g., polysorbates such as “TWEEN 20”and “TWEEN 80”), sorbitan esters, saccharin (e.g., sodium saccharin orother saccharin forms, which as noted elsewhere herein may be present incertain embodiments at specific concentrations or at specific molarratios relative to a pyridone analog compound such as pirfenidone),bicarbonate, cyclodextrins, lipids (e.g., phospholipids such as lecithinand other phosphatidylcholines, phosphatidylethanolamines), fatty acidsand fatty esters, steroids (e.g., cholesterol), and chelating agents(e.g., EDTA, zinc and other such suitable cations). Other pharmaceuticalexcipients and/or additives suitable for use in the compositionsaccording to the invention are listed in “Remington: The Science &Practice of Pharmacy”, 19^(th) ed., Williams & Williams, (1995), and inthe “Physician's Desk Reference”, 52^(nd) ed., Medical Economics,Montvale, N.J. (1998).

By way of non-limiting example, taste-masking agents in pirfenidone orpyridone analog compound formulations, may include the use offlavorings, sweeteners, and other various coating strategies, forinstance, sugars such as sucrose, dextrose, and lactose, carboxylicacids, menthol, amino acids or amino acid derivatives such as arginine,lysine, and monosodium glutamate, and/or synthetic flavor oils andflavoring aromatics and/or natural oils, extracts from plants, leaves,flowers, fruits, etc. and combinations thereof. These may includecinnamon oils, oil of wintergreen, peppermint oils, clover oil, bay oil,anise oil, eucalyptus, vanilla, citrus oil such as lemon oil, orangeoil, grape and grapefruit oil, fruit essences including apple, peach,pear, strawberry, raspberry, cherry, plum, pineapple, apricot, etc.Additional sweeteners include sucrose, dextrose, aspartame(Nutrasweet®), acesulfame-K, sucralose and saccharin (e.g., sodiumsaccharin or other saccharin forms, which as noted elsewhere herein maybe present in certain embodiments at specific concentrations or atspecific molar ratios relative to a pyridone analog compound such aspirfenidone), organic acids (by non-limiting example citric acid andaspartic acid). Such flavors may be present at from about 0.05 to about4 percent by weight, and may be present at lower or higher amounts as afactor of one or more of potency of the effect on flavor, solubility ofthe flavorant, effects of the flavorant on solubility or otherphysicochemical or pharmacokinetic properties of other formulationcomponents, or other factors.

Another approach to improve or mask the unpleasant taste of an inhaleddrug may be to decrease the drug's solubility, e.g., drugs must dissolveto interact with taste receptors. Hence, to deliver solid forms of thedrug may avoid the taste response and result in the desired improvedtaste affect. Non-limiting methods to decrease solubility of apirfenidone or pyridone analog compound solubility are described herein,for example, through the use in formulation of particular salt forms ofpyridone analog compound, such as complexation with xinafoic acid, oleicacid, stearic acid and/or pamoic acid. Additional co-precipitatingagents include dihydropyridines and a polymer such as polyvinylpyrrolidone.

Moreover, taste-masking may be accomplished by creation of lipopilicvesicles. Additional coating or capping agents include dextrates (bynon-limiting example cyclodextrins may include,2-hydroxypropyl-beta-cyclodextrin, 2-hydroxypropyl-gamma-cyclodextrin,randomly methylated beta-cyclodextrin, dimethyl-alpha-cyclodextrin,dimethyl-beta-cyclodextrin, maltosyl-alpha-cyclodextrin,glucosyl-1-alpha-cyclodextrin, glucosyl-2-alpha-cyclodextrin,alpha-cyclodextrin, beta-cyclodextrin, gamma-cyclodextrin, andsulfobutylether-beta-cyclodextrin), modified celluloses such as ethylcellulose, methyl cellulose, hydroxypropyl cellulose, hydroxyl propylmethyl cellulose, polyalkylene glycols, polyalkylene oxides, sugars andsugar alcohols, waxes, shellacs, acrylics and mixtures thereof. Bynon-limiting example, other methods to deliver non-dissolved forms of apirfenidone or pyridone analog compound according to certain embodimentsor, in other embodiments, non-dissolved forms of a pirfenidone orpyridone analog compound, are to administer the drug alone or in asimple, non-solubility affecting formulation, such as a crystallinemicronized, dry powder, spray-dried, and/or nanosuspension formulation.

An alternative according to certain other preferred embodiments is toinclude taste-modifying agents in the pirfenidone or pyridone analogcompound formulation. These embodiments contemplate including in theformulation a taste-masking substance that is mixed with, coated onto orotherwise combined with the active medicament pirfenidone or pyridoneanalog compound or salt thereof. Inclusion of one or more such agents inthese formulations may also serve to improve the taste of additionalpharmacologically active compounds that are included in the formulationsin addition to the pirfenidone or pyridone analog compound, e.g., amucolytic agent. Non-limiting examples of such taste-modifyingsubstances include acid phospholipids, lysophospholipid, tocopherolpolyethyleneglycol succinate, and embonic acid (pamoate). Many of theseagents can be used alone or in combination with pirfenidone or pyridoneanalog compound (or a salt thereof) or, in separate embodiments,pirfenidone or pyridone analog compound for aerosol administration.

Mucolytic Agents

Methods to produce formulations that combine agents to reduce sputumviscosity during aerosol treatment with a pirfenidone or pyridone analogcompound include the following. These agents can be prepared in fixedcombination or be administered in succession with aerosol pirfenidone orpyridone analog compound therapy.

The most commonly prescribed agent is N-acetylcysteine (NAC), whichdepolymerizes mucus in vitro by breaking disulphide bridges betweenmacromolecules. It is assumed that such reduction of sputum tenacityfacilitates its removal from the respiratory tract. In addition, NAC mayact as an oxygen radical scavenger. NAC can be taken either orally or byinhalation. Differences between these two methods of administration havenot been formally studied. After oral administration, NAC is reduced tocysteine, a precursor of the antioxidant glutathione, in the liver andintestine. The antioxidant properties could be useful in preventingdecline of lung function in cystic fibrosis (CF), chronic obstructivepulmonary disease (COPD) or pulmonary fibrotic diseases (e.g.,idiopathic pulmonary fibrosis). Nebulized NAC is commonly prescribed topatients with CF, in particular in continental Europe, in order toimprove expectoration of sputum by reducing its tenacity. The ultimategoal of this is to slow down the decline of lung function in CF.

L-lysine-N-acetylcysteinate (ACC) or Nacystelyn (NAL) is a novelmucoactive agent possessing mucolytic, antioxidant, andanti-inflammatory properties. Chemically, it is a salt of ACC. This drugappears to present an activity superior to its parent molecule ACCbecause of a synergistic mucolytic activity of L-lysine and ACC.Furthermore, its almost neutral pH (6.2) allows its administration inthe lungs with a very low incidence of bronchospasm, which is not thecase for the acidic ACC (pH 2.2). NAL is difficult to formulate in aninhaled form because the required lung dose is very high (approximately2 mg) and the micronized drug is sticky and cohesive and it is thusproblematic to produce a redispersible formulation. NAL was firstdeveloped as a chlorofluorocarbon (CFC) containing metered-dose inhaler(MDI) because this form was the easiest and the fastest to develop tobegin the preclinical and the first clinical studies. NAL MDI delivered2 mg per puff, from which approximately 10% was able to reach the lungsin healthy volunteers. One major inconvenience of this formulation waspatient compliance because as many as 12 puffs were necessary to obtainthe required dose. Furthermore, the progressive removal of CFC gasesfrom medicinal products combined with the problems of coordination metin a large proportion of the patient population (12) have led to thedevelopment of a new galenical form of NAL. A dry powder inhaler (DPI)formulation was chosen to resolve the problems of compliance with MDIsand to combine it with an optimal, reproducible, and comfortable way toadminister the drug to the widest possible patient population, includingyoung children.

The DPI formulation of NAL involved the use of a nonconventional lactose(usually reserved for direct compression of tablets), namely, aroller-dried (RD) anhydrous p3-lactose. When tested in vitro with amonodose DPI device, this powder formulation produces a fine particlefraction (FPF) of at least 30% of the nominal dose, namely three timeshigher than that with MDIs. This approach may be used in combinationwith a pirfenidone or pyridone analog compound for eitherco-administration or fixed combination therapy.

In addition to mucolytic activity, excessive neutrophil elastaseactivity within airways of cystic fibrosis (CF) patients results inprogressive lung damage. Disruption of disulfide bonds on elastase byreducing agents may modify its enzymatic activity. Three naturallyoccurring dithiol reducing systems were examined for their effects onelastase activity: 1) Escherichia coli thioredoxin (Trx) system, 2)recombinant human thioredoxin (rhTrx) system, and 3) dihydrolipoic acid(DHLA). The Trx systems consisted of Trx, Trx reductase, and NADPH. Asshown by spectrophotometric assay of elastase activity, the two Trxsystems and DHLA inhibited purified human neutrophil elastase as well asthe elastolytic activity present in the soluble phase (sol) of CFsputum. Removal of any of the three Trx system constituents preventedinhibition. Compared with the monothiols N-acetylcysteine and reducedglutathione, the dithiols displayed greater elastase inhibition. Tostreamline Trx as an investigational tool, a stable reduced form ofrhTrx was synthesized and used as a single component. Reduced rhTrxinhibited purified elastase and CF sputum sol elastase without NADPH orTrx reductase. Because Trx and DHLA have mucolytic effects, weinvestigated changes in elastase activity after mucolytic treatment.Unprocessed CF sputum was directly treated with reduced rhTrx, the Trxsystem, DHLA, or DNase. The Trx system and DHLA did not increaseelastase activity, whereas reduced rhTrx treatment increased solelastase activity by 60%. By contrast, the elastase activity after DNasetreatment increased by 190%. The ability of Trx and DHLA to limitelastase activity combined with their mucolytic effects makes thesecompounds potential therapies for CF.

In addition, bundles of F-actin and DNA present in the sputum of cysticfibrosis (CF) patients but absent from normal airway fluid contribute tothe altered viscoelastic properties of sputum that inhibit clearance ofinfected airway fluid and exacerbate the pathology of CF. One approachto alter these adverse properties is to remove these filamentousaggregates using DNase to enzymatically depolymerize DNA to constituentmonomers and gelsolin to sever F-actin to small fragments. The highdensities of negative surface charge on DNA and F-actin suggest that thebundles of these filaments, which alone exhibit a strong electrostaticrepulsion, may be stabilized by multivalent cations such as histones,antimicrobial peptides, and other positively charged molecules prevalentin airway fluid. Furthermore, as a matter-a-fact, it has been observedthat bundles of DNA or F-actin formed after addition of histone H1 orlysozyme are efficiently dissolved by soluble multivalent anions such aspolymeric aspartate or glutamate. Addition of poly-aspartate orpoly-glutamate also disperses DNA and actin-containing bundles in CFsputum and lowers the elastic moduli of these samples to levelscomparable to those obtained after treatment with DNase I or gelsolin.Addition of poly-aspartic acid also increased DNase activity when addedto samples containing DNA bundles formed with histone H1. When added toCF sputum, poly-aspartic acid significantly reduced the growth ofbacteria, suggesting activation of endogenous antibacterial factors.These findings suggest that soluble multivalent anions have potentialalone or in combination with other mucolytic agents to selectivelydissociate the large bundles of charged biopolymers that form in CFsputum.

Hence, NAC, unfractionated heparin, reduced glutathione, dithiols, Trx,DHLA, other monothiols, DNAse, dornase alfa, hypertonic formulations(e.g., osmolalities greater than about 350 mOsmol/kg), multivalentanions such as polymeric aspartate or glutamate, glycosidases and otherexamples listed above can be combined with pirfenidone or pyridoneanalog compounds and other mucolytic agents for aerosol administrationto improve antifibrotic and/or antiinflammatory activity through betterdistribution from reduced sputum viscosity, and improved clinicaloutcome through improved pulmonary function (from improved sputummobility and mucociliary clearance) and decreased lung tissue damagefrom the immune inflammatory response.

Characterization of Inhalation Devices

The efficiency of a particular inhalation device can be measured by manydifferent ways, including an analysis of pharmacokinetic properties,measurement of lung deposition percentage, measurement of respirabledelivery dose (RDD), a determination of output rates, geometric standarddeviation values (GSD), and mass median aerodynamic diameter values(MMAD) among others.

Methods and systems for examining a particular inhalation device areknown. One such system consists of a computer means and a hollowcylinder in a pump means with a connecting piece to which an inhalationdevice is to be connected. In the pump means there is a piston rod,which extends out of the hollow cylinder. A linear drive unit can beactivated in such a manner that one or more breathing pattern will besimulated on the connecting piece of the pump means. In order to be ableto carry out the evaluation of the inhalation device, the computer isconnected in an advantageous configuration with a data transmissionmeans. With the aid of the data transmission means, the computer can beconnected with another computer with specific data banks, in order toexchange the data of breathing patterns. In this manner, a breathingpattern library which is as representative as possible can be veryrapidly formed. U.S. Pat. No. 6,106,479 discloses this method forexamining an inhalation device in more detail, and is herebyincorporated by reference in its entirety.

Pharmacokinetic Profile

Pharmacokinetics is concerned with the uptake, distribution, metabolismand excretion of a drug substance. A pharmacokinetic profile comprisesone or more biological measurements designed to measure the absorption,distribution, metabolism and excretion of a drug substance. One way ofvisualizing a pharmacokinetic profile is by means of a blood plasmaconcentration curve, which is a graph depicting mean active ingredientblood plasma concentration on the Y-axis and time (usually in hours) onthe X-axis. Some pharmacokinetic parameters that may be visualized bymeans of a blood plasma concentration curve include:

-   -   Cmax: The maximum plasma concentration in a patient.    -   AUC: area under the curve    -   TOE: time of exposure    -   T½: period of time it takes for the amount in a patient of drug        to decrease by half    -   T_(max): The time to reach maximum plasma concentration in a        patient

Pharmacokinetics (PK) is concerned with the time course of a therapeuticagent, such as pirfenidone, or a pyridone analog compound concentrationin the body. Pharmacodynamics (PD) is concerned with the relationshipbetween pharmacokinetics and efficacy in vivo. PK/PD parameterscorrelate the therapeutic agent, such as exposure with efficaciousactivity. Accordingly, to predict the therapeutic efficacy of atherapeutic agent, such as with diverse mechanisms of action differentPK/PD parameters may be used.

Any standard pharmacokinetic protocol can be used to determine bloodplasma concentration profile in humans following administration of aformulation comprising pirfenidone or a pyridone analog compounddescribed herein, and thereby establish whether that formulation meetsthe pharmacokinetic criteria set out herein. For example, but in no waylimiting, a type of a randomized single-dose crossover study can beutilized using a group of healthy adult human subjects. The number ofsubjects can be sufficient to provide adequate control of variation in astatistical analysis, and is typically about 8 or greater, although incertain embodiments a smaller group can be used. In one embodiment, asubject receives administration, at time zero, a single dose of a testinhalation mixture comprising pirfenidone or a pyridone analog compound.Blood samples are collected from each subject prior to administrationand at several intervals after administration. Plasma can be separatedfrom the blood samples by centrifugation and the separated plasma isanalyzed, for example, by a validated high performance liquidchromatography/tandem weight spectrometry (LC/APCI-MS/MS) procedure suchas, for example, those described in Ramu et al., Journal ofChromatography B, 751:49-59 (2001). In other embodiments, data from asingle subject may be collected and may be used to construct a pKprofile and may be indicative of an enhanced pharmacokinetic profile. Instill other embodiments, appropriate in vitro models may be used toconstruct a pK profile and may be demonstrate or indicate an enhancedpharmacokinetic profile.

In some embodiments, a human pK profile can be may be obtained by theuse of allometric scaling. In one embodiment, rat aerosol lung data andplasma delivery is scaled to provide an indication of possible humansdata. In one embodiment, allometric scaling uses parameters establishedin the US FDA Guidance for Industry—Estimating the Maximum Safe StartingDose in Initial Clinical Trials for Therapeutics in Adult HealthyVolunteers.

Any aqueous inhalable mixture giving the desired pharmacokinetic profilemay be suitable for administration according to the present methods.

As used herein, the “peak period” of a pharmaceutical's in vivoconcentration is defined as that time of the pharmaceutical dosinginterval when the pharmaceutical concentration is not less than 50% ofits maximum plasma or site-of-disease concentration. In someembodiments, “peak period” is used to describe an interval ofpirfenidone or a pyridone analog compound dosing.

In some embodiments, when considering treatment of lung diseases, amethod or system described herein provides at least a two-foldenhancement in pharmacokinetic profile for treatment of the lungdisease. In some embodiments, the methods and systems described hereinprovide at least a two-fold enhancement in the lung tissuepharmacokinetic profile of pirfenidone or pyridone analog compound ascompared to oral administration.

In some embodiments, a delayed appearance of 5-carboxy-pirfenidone (theprimary pirfenidone liver metabolite) has been observed from the methodsand systems described herein. In some embodiments, rapid elimination ofpirfenidone from the lung tissue has been observed. Comparing theinitial rapid elimination of pirfenidone from the lung tissue andparallel appearance of pirfenidone in the plasma suggest that directpulmonary administration may be a good route for systemic administrationof pirfenidone. The delayed appearance of 5-carboxy-pirfenidonemetabolite supports this hypothesis in that this metabolite serves as amarker for re-circulation of pirfenidone to the lung and other tissuesfollowing direct aerosol administration to the lung. In someembodiments, re-circulated pirfenidone is likely important to supportlong-term, elevated pirfenidone levels in the lung and other tissues ofpotential efficacy.

In some embodiments, the amount of pirfenidone or pyridone analogcompound that is administered to a human by inhalation may be calculatedby measuring the amount of pirfenidone or pyridone analog compound andassociated metabolites that are found in the urine. In some embodiments,about 80% of administered pirfenidone is excreted in the urine (with 95%being the primary metabolite, 5-carboxy-pirfenidone). In someembodiments, the calculation based on compound and metabolites in urinemay be done through a 48 urine collection (following a singleadministration), whereby the total amount of pirfenidone or pyridoneanalog compound delivered to the human is the sum of measuredpirfenidone and its metabolites. By non-limiting example, knowing that80% of pirfenidone is excreted, a 50 mg sum urinary measurement ofpirfenidone and its metabolites would translate to a delivered dose ofabout 63 mg (50 mg divided by 80%). If by non-limiting example theinhaled aerosol fine-particle fraction (FPF) is 75%, one may assume thatabout 75% of the drug deposited in the lung (and about 25% wasswallowed, and subsequently absorbed from the gut with 80% excreted inthe urine). Integrating these two calculations, of a 63 mg delivereddose (as measured by urinary excretion), about 47 mg would be the amountof inhaled aerosol pirfenidone delivered to the lung (the actual RDD;calculated as the product of 63 mg and a 75% FPF). This RDD can then beused in a variety of calculations, including lung tissue concentration.

In some embodiments, method or systems described herein providepharmacokinetic profiles of pirfenidone or pyridone analog compounds asdescribed herein. In some embodiments, method or systems describedherein provide pharmacokinetic profiles of pirfenidone or pyridoneanalog compounds as in Examples 6 and 7.

In some embodiments, efficacy of pirfenidone or pyridone analogcompounds in the treatment of pulmonary fibrosis is achieved throughrepeated administration to a human by inhalation. As shown in Examples 6and 7, administration of pirfenidone or pyridone analog compounds to ahuman by inhalation provides higher Cmax levels as compared to oraldelivery. In some embodiments, solutions of pirfenidone or pyridoneanalog compounds that are administered by inhalation provide higher Cmaxlevels as compared to oral delivery. In some embodiments, the peakperiod is used to define the optimal dosing schedule of the pirfenidoneor pyridone analog compound. In some embodiments, solutions ofpirfenidone or pyridone analog compounds are administered more than oncea week.

Small intratracheal aerosol doses deliver a rapidly-eliminated high lungCmax and low AUC. Human, animal and in vitro studies all indicate thatpirfenidone efficacy is dose responsive (i.e. larger doses correlatewith improved efficacy) and suggest Cmax is a key driver in pirfenidoneefficacy. While lung Cmax appears important for efficacy, more regularpirfenidone exposure also appears important to enhance this effect. Insome embodiments, in the context of treating lung diseases in a human,more frequent direct-lung administration of pirfenidone or pyridoneanalog compound may provide benefit through both repeat high Cmax dosingand providing more regular exposure of the active therapeutic agent.

In some embodiments, described herein is a method for the treatment oflung disease in a mammal comprising administering directly to the lungsof the mammal in need thereof pirfenidone or a pyridone analog compoundon a continuous dosing schedule, wherein the observed lung tissue Cmaxof a dose of pirfenidone or a pyridone analog compound is greater than0.1 mcg/gram lung tissue. In some embodiments, the observed lung tissueCmax from a dose of pirfenidone or a pyridone analog compound is greaterthan 0.5 mcg/gram lung tissue. In some embodiments, the observed lungtissue Cmax from a dose of pirfenidone or a pyridone analog compound isgreater than 1.0 mcg/gram lung tissue. In some embodiments, the observedlung tissue Cmax from a dose of pirfenidone or a pyridone analogcompound is greater than 5 mcg/gram lung tissue. In some embodiments,the observed lung tissue Cmax from a dose of pirfenidone or a pyridoneanalog compound is greater than 10 mcg/gram lung tissue. In someembodiments, the observed lung tissue Cmax from a dose of pirfenidone ora pyridone analog compound is greater than 15 mcg/gram lung tissue. Insome embodiments, the observed lung tissue Cmax from a dose ofpirfenidone or a pyridone analog compound is greater than 20 mcg/gramlung tissue. In some embodiments, the observed lung tissue Cmax from adose of pirfenidone or a pyridone analog compound is greater than 25mcg/gram lung tissue. In some embodiments, the observed lung tissue Cmaxfrom a dose of pirfenidone or a pyridone analog compound is greater than30 mcg/gram lung tissue. In some embodiments, the observed lung tissueCmax from a dose of pirfenidone or a pyridone analog compound is greaterthan 35 mcg/gram lung tissue. In some embodiments, the observed lungtissue Cmax from a dose of pirfenidone or a pyridone analog compound isgreater than 40 mcg/gram lung tissue. In some embodiments, the observedlung tissue Cmax from a dose of pirfenidone or a pyridone analogcompound is greater than 45 mcg/gram lung tissue. In some embodiments,the observed lung tissue Cmax from a dose of pirfenidone or a pyridoneanalog compound is greater than 50 mcg/gram lung tissue. In someembodiments, the dose comprises an aqueous solution of pirfenidone or apyridone analog compound. In some embodiments, the dose is administeredwith a liquid nebulizer. In some embodiments, the pirfenidone or apyridone analog compound is administered more than once a week. In someembodiments, the pirfenidone or a pyridone analog compound isadministered on a continuous daily dosing schedule. In some embodiments,the single doses of pirfenidone or a pyridone analog compound isadministered more than once a week, more than twice a week, more thanthree times a week, more than four times a week, more than five times aweek more than six times a week or daily. In some embodiments, thepirfenidone or a pyridone analog compound is administered on acontinuous daily dosing schedule. In some embodiments, the pirfenidoneor a pyridone analog compound is administered once a day, twice a day,or three times a day.

In some embodiments, described herein is a method for the treatment oflung disease in a mammal comprising administering directly to the lungsof the mammal in need thereof pirfenidone or a pyridone analog compoundon a continuous dosing schedule. In some embodiments, a) the lung tissueCmax of pirfenidone or pyridone analog compound from a dose that isdirectly administered to the lungs of the mammal is at least equivalentto or greater than a lung tissue Cmax of up to 801 mg of an orallyadministered dosage of pirfenidone or pyridone analog compound; and/orb) the blood AUC₀₋₂₄ of pirfenidone or pyridone analog compound from adose that is directly administered to the lungs of the mammal is lessthan or equivalent to the blood AUC₀₋₂₄ of up to 801 mg of an orallyadministered dosage of pirfenidone or pyridone analog compound. In someembodiments, a) the lung tissue Cmax of pirfenidone or pyridone analogcompound from a dose that is directly administered to the lungs of themammal is at least equivalent to or greater than a lung tissue Cmax ofup to 801 mg of an orally administered dosage of pirfenidone or pyridoneanalog compound; and b) the blood AUC₀₋₂₄ of pirfenidone or pyridoneanalog compound from a dose that is directly administered to the lungsof the mammal is less than or equivalent to the blood AUC₀₋₂₄ of up to801 mg of an orally administered dosage of pirfenidone or pyridoneanalog compound. In some embodiments, a) the lung tissue Cmax ofpirfenidone or pyridone analog compound from a dose that is directlyadministered to the lungs of the mammal is at least equivalent to orgreater than a lung tissue Cmax of up to 801 mg of an orallyadministered dosage of pirfenidone or pyridone analog compound; or b)the blood AUC₀₋₂₄ of pirfenidone or pyridone analog compound from a dosethat is directly administered to the lungs of the mammal is less than orequivalent to the blood AUC₀₋₂₄ of up to 801 mg of an orallyadministered dosage of pirfenidone or pyridone analog compound. In someembodiments, the dose comprises an aqueous solution of pirfenidone or apyridone analog compound. In some embodiments, the dose is administeredwith a liquid nebulizer. In some embodiments, the pirfenidone or apyridone analog compound is administered more than once a week. In someembodiments, the single doses of pirfenidone or a pyridone analogcompound is administered more than once a week, more than twice a week,more than three times a week, more than four times a week, more thanfive times a week more than six times a week or daily. In someembodiments, the pirfenidone or a pyridone analog compound isadministered on a continuous daily dosing schedule. In some embodiments,the pirfenidone or a pyridone analog compound is administered once aday, twice a day, or three times a day.

Methods of Dosing and Treatment Regimens

In one aspect, pirfenidone or a pyridone analog compound is administereddaily to humans in need of therapy with pirfenidone or a pyridone analogcompound. In some embodiments, pirfenidone or a pyridone analog compoundis administered by inhalation to the human. In some embodiments,pirfenidone or a pyridone analog compound is administered once-a-day. Insome embodiments, pirfenidone or a pyridone analog compound isadministered twice-a-day. In some embodiments, pirfenidone or a pyridoneanalog compound is administered three times-a-day. In some embodiments,pirfenidone or a pyridone analog compound is administered every otherday. In some embodiments, pirfenidone or a pyridone analog compound isadministered twice a week.

In general, doses of pirfenidone or a pyridone analog compound employedfor treatment of the diseases or conditions described herein in humansare typically in the range of from about 0.001 mg to about 10 mgpirfenidone/kg of body weigh per dose. In one embodiment, the desireddose is conveniently presented in a single dose or in divided dosesadministered simultaneously (or over a short period of time) or atappropriate intervals, for example as two, three, four or more sub-dosesper day. In some embodiments, pirfenidone or a pyridone analog compoundis conveniently presented in divided doses that are administeredsimultaneously (or over a short period of time) once a day. In someembodiments, pirfenidone or a pyridone analog compound is convenientlypresented in divided doses that are administered in equal portionstwice-a-day.

In some embodiments, pirfenidone or a pyridone analog compound isadministered by inhalation daily to the human. In some embodiments,pirfenidone or a pyridone analog compound is administered orally to thehuman at a dose from about 0.001 mg to about 10 mg pirfenidone/kg ofbody weigh per dose. In some embodiments, pirfenidone or a pyridoneanalog compound is administered by inhalation to the human on acontinuous daily dosing schedule.

The term “continuous dosing schedule” refers to the administration of aparticular therapeutic agent at regular intervals. In some embodiments,continuous dosing schedule refers to the administration of a particulartherapeutic agent at regular intervals without any drug holidays fromthe particular therapeutic agent. In some other embodiments, continuousdosing schedule refers to the administration of a particular therapeuticagent in cycles. In some other embodiments, continuous dosing schedulerefers to the administration of a particular therapeutic agent in cyclesof drug administration followed by a drug holiday (for example, a washout period or other such period of time when the drug is notadministered) from the particular therapeutic agent. For example, insome embodiments the therapeutic agent is administered once a day, twicea day, three times a day, once a week, twice a week, three times a week,four times a week, five times a week, six times a week, seven times aweek, every other day, every third day, every fourth day, daily for aweek followed by a week of no administration of the therapeutic agent,daily for a two weeks followed by one or two weeks of no administrationof the therapeutic agent, daily for three weeks followed by one, two orthree weeks of no administration of the therapeutic agent, daily forfour weeks followed by one, two, three or four weeks of noadministration of the therapeutic agent, weekly administration of thetherapeutic agent followed by a week of no administration of thetherapeutic agent, or biweekly administration of the therapeutic agentfollowed by two weeks of no administration of the therapeutic agent. Insome embodiments, daily administration is once a day. In someembodiments, daily administration is twice a day. In some embodiments,daily administration is three times a day. In some embodiments, dailyadministration is more than three times a day.

The term “continuous daily dosing schedule” refers to the administrationof a particular therapeutic agent everyday at roughly the same time eachday. In some embodiments, daily administration is once a day. In someembodiments, daily administration is twice a day. In some embodiments,daily administration is three times a day. In some embodiments, dailyadministration is more than three times a day.

In some embodiments, the amount of pirfenidone or a pyridone analogcompound is administered once-a-day. In some other embodiments, theamount of pirfenidone or a pyridone analog compound is administeredtwice-a-day. In some other embodiments, the amount of pirfenidone or apyridone analog compound is administered three times a day.

In certain embodiments wherein improvement in the status of the diseaseor condition in the human is not observed, the daily dose of pirfenidoneor a pyridone analog compound is increased. In some embodiments, aonce-a-day dosing schedule is changed to a twice-a-day dosing schedule.In some embodiments, a three times a day dosing schedule is employed toincrease the amount of pirfenidone or a pyridone analog compound that isadministered. In some embodiments, the frequency of administration byinhalation is increased in order to provide repeat high Cmax levels on amore regular basis. In some embodiments, the frequency of administrationby inhalation is increased in order to provide maintained or moreregular exposure to pirfenidone. In some embodiments, the frequency ofadministration by inhalation is increased in order to provide repeathigh Cmax levels on a more regular basis and provide maintained or moreregular exposure to pirfenidone.

In some embodiments, the amount of repeat high Cmax dosing providingmore regular exposure of the active therapeutic agent that is given tothe human varies depends upon factors such as, but not limited to,condition and severity of the disease or condition, and the identity(e.g., weight) of the human, and the particular additional therapeuticagents that are administered (if applicable).

EXAMPLES Example 1: Pirfenidone Formulations

Non-limiting examples of compositions of pirfenidone include thosedescribed in Table 1-1 through Table 1-11.

TABLE 1-1 Ingredient and Amount Phosphate Phosphate Citrate BufferBuffer (sodium Buffer (sodium (acid/sodium Sodium Magnesium Compositionsalt), pH 6.2 salt), pH 7.3 salt), pH 5.8 Chloride Chloride no.Pirfenidone (mM) (mM) (mM) (μmols) (μmols) Water 1 1 mg to — — 0.01 mMto — — q.s. to 500 mg 500 mM 5 mL (5 μmols to 3 mmols) 2 1 mg to 0.01 mMto — — — — q.s. to 500 mg 500 mM 5 mL (5 μmols to 3 mmols) 3 1 mg to —0.01 mM to — — — q.s. to 500 mg 500 mM 5 mL (5 μmols to 3 mmols) 4 54μmols 0.01 to — — 150  — q.s. to 500 5 mL 5 54 μmols — 0.01 to — 150  —q.s. to 500 5 mL 6 54 μmols — — 0.01 to 150  — q.s. to 500 5 mL 7 54μmols 0.01 to — — — 150  q.s. to 500 5 mL 8 54 μmols — 0.01 to — — 150 q.s. to 500 5 mL 9 54 μmols — — 0.01 to — 150  q.s. to 500 5 mL 10 54μmols 0.01 to — —   13.5 — q.s. to 500 5 mL 11 54 μmols — 0.01 to —  13.5 — q.s. to 500 5 mL 12 54 μmols — — 0.01 to   13.5 — q.s. to 500 5mL 13 54 μmols 0.01 to — — —   13.5 q.s. to 500 5 mL 14 54 μmols — 0.01to — —   13.5 q.s. to 500 5 mL 15 54 μmols — — 0.01 to —   13.5 q.s. to500 5 mL 16 54 μmols 0.01 to — — 54 — q.s. to 500 5 mL 17 54 μmols —0.01 to — 54 — q.s. to 500 5 mL 18 54 μmols — — 0.01 to 54 — q.s. to 5005 mL 19 54 μmols 0.01 to — — — 54 μmols q.s. to 500 5 mL 20 54 μmols —0.01 to — — 54 μmols q.s. to 500 5 mL 21 54 μmols — — 0.01 to — 54 μmolsq.s. to 500 5 mL 22 54 μmols 0.01 to — — 27 — q.s. to 500 5 mL 23 54μmols — 0.01 to — 27 — q.s. to 500 5 mL 24 54 μmols — — 0.01 to 27 —q.s. to 500 5 mL 25 54 μmols 0.01 to — — — 27 q.s. to 500 5 mL 26 54μmols — 0.01 to — — 27 q.s. to 500 5 mL 27 54 μmols — — 0.01 to — 27q.s. to 500 5 mL

TABLE 1-2 Ingredient and Amount Phosphate Buffer Citrate Buffer(monobasic/dibasic Sodium Saccharin Composition (acid/sodium salt),sodium salts), pH Chloride Magnesium (sodium no. Pirfenidone pH 2.0 to9.0 (mM) 2.0 to 9.0 (mM) (μmols) Chloride salt) (mM) Water 28 5 μmols to0.01 to — — 1 μmol to 0.01 to q.s. to 3 mmols 500 15 mmols 10.0 5 mL 295 μmols to — 0.01 to — 1 μmol to 0.01 to q.s. to 3 mmols 500 15 mmols10.0 5 mL 30 5 μmols to 0.01 to — 1 μmol to — 0.01 to q.s. to 3 mmols500 15 mmols 10.0 5 mL 31 5 μmols to — 0.01 to 1 μmol to — 0.01 to q.s.to 3 mmols 500 15 mmols 10.0 5 mL

TABLE 1-3 Ingredient and Amount Citrate Buffer Phosphate BufferPhosphate Buffer (acid/sodium (monobasic/dibasic (monobasic/dibasicSaccharin Composition salt), pH 5.8 sodium salts), pH sodium salts), pH(sodium no. Pirfenidone (mM) 6.2 (mM) 7.3 (mM) salt) (mM) Water 32 1 mgto 500 0.01 to — — 0.01 to q.s. to mg (5 μmols 500 10.0 5 mL to 3 mmols)33 1 mg to 500 — 0.01 to — 0.01 to q.s. to mg (5 μmols 500 10.0 5 mL to3 mmols) 34 1 mg to 500 0.01 to 0.01 to q.s. to mg (5 μmols 500 10.0 5mL to 3 mmols)

In some embodiments, pirfenidone exhibited aqueous solubility to ˜17mg/mL across a pH range of about 4.0 to about 8.0. However, at this (andlower) concentration it was determined that salt addition was requiredto improve acute tolerability upon inhalation of a nebulized solution(otherwise a hypotonic solution). To address tonicity, NaCl or MgCl₂were added. In some embodiments, addition of NaCl improved acutetolerability, but destabilized the formulation and resulted inprecipitation upon ambient storage. In some embodiments, it wasdetermined that addition of MgCl₂ maintained a stable, soluble solutionat this concentration with an osmolality in a tolerable range. Bynon-limiting example, 81 mM MgCl₂ provides a 1:1 mole ratio of magnesiumto pirfenidone where pirfenidone is at 15 mg/mL (or 81 mM). This effectwas also observed at various pirfenidone concentrations with 1:1 and 1:2mole ratios of magnesium to pirfenidone, but not at ratios less than orequal to 0.25:1 or greater than or equal to 1:0.33 magnesium topirfenidone, respectively. This effect was observed in 5 mM to 50 mMcitrate buffer at pH 4.0 and pH 5.8, and 5 mM to 50 mM phosphate bufferat pH 6.2, pH 7.3 and pH 7.8. Other observations included: 1)Formulations of both buffer systems exhibited a metallic, bitter flavorand throat irritation; 2) From 0.1 to 0.7 mM sodium saccharin wasrequired to taste mask these formulations; 3) 0.6 mM sodium saccharinwas the best concentration and improved the flavor of 2:1 mol ratiopirfenidone to magnesium in phosphate buffer more so than the 1:1 molratio; 4) The taste of 2:1 mol ratio pirfenidone to magnesium in citratebuffer without sodium saccharin was equivalent to the 1:1 mol ratiopirfenidone to magnesium in phosphate buffer with 0.6 mM sodiumsaccharin; 5) The taste of 2:1 mol ratio pirfenidone to magnesium incitrate buffer with 0.2 mM sodium saccharin was equivalent to the 2:1mol ratio pirfenidone to magnesium in phosphate buffer with 0.6 mMsodium saccharin; 6) The taste of 1:1 mol ratio pirfenidone to magnesiumin citrate buffer with 0.6 mM sodium saccharin was equivalent to 2:1 molratio pirfenidone to magnesium in phosphate buffer 0.6 mM sodiumsaccharin; and 7) 1:1 mol ratio pirfenidone to magnesium dissolved in upto 40% the time required to dissolve 2:1 mol ratio pirfenidone tomagnesium in either buffer system at ˜pH 6. This effect was not observedat ˜pH 8.

TABLE 1-4 Ingredient and Amount Phosphate Buffer (monobasic/dibasicPropylene Cetylpyridinium Composition Pirfenidone sodium salts), pHEthanol Glycol Glycerol Polysorbate Bromide (or Osmolality no. (mg) 5.5to 8.5 (mM) (% v/v) (% v/v) (% v/v) 80 (% v/v) chloride) (%) (mOsmo/kg)Water 35 1 to 0.01 to 0.001 to — — — — 50 to q.s. to 500 500 25 5000 5mL  36* 1 to 0.01 to — 0.001 to — — — 50 to q.s. to 500 500 25 5000 5 mL37 1 to 0.01 to — — 0.001 to — — 50 to q.s. to 500 500 25 5000 5 mL 38 1to 0.01 to — — — 0.0001 to — 50 to q.s. to 500 500 1.0 5000 5 mL  39* 1to 0.01 to — — — — 0.0001 to 50 to q.s. to 500 500 5.0 5000 5 mL 40 1 to0.01 to 0.001 to 0.001 to — — — 50 to q.s. to 500 500 25 25 5000 5 mL 411 to 0.01 to 0.001 to — 0.001 to — — 50 to q.s. to 500 500 25 25 5000 5mL 42 1 to 0.01 to 0.001 to — — 0.0001 to — 50 to q.s. to 500 500 25 1.05000 5 mL 43 1 to 0.01 to 0.001 to — — — 0.0001 to 50 to q.s. to 500 50025 5.0 5000 5 mL 44 1 to 0.01 to 0.001 to 0.001 to 0.001 to — — 50 toq.s. to 500 500 25 25 25 5000 5 mL 45 1 to 0.01 to 0.001 to 0.001 to —0.0001 to — 50 to q.s. to 500 500 25 25 1.0 5000 5 mL 46 1 to 0.01 to0.001 to 0.001 to — — 0.0001 to 50 to q.s. to 500 500 25 25 5.0 5000 5mL 47 1 to 0.01 to 0.001 to 0.001 to 0.001 to 0.0001 to — 50 to q.s. to500 500 25 25 25 1.0 5000 5 mL 48 1 to 0.01 to 0.001 to 0.001 to —0.0001 to — 50 to q.s. to 500 500 25 25 1.0 5000 5 mL 49 1 to 0.01 to0.001 to 0.001 to 0.001 to — 0.0001 to 50 to q.s. to 500 500 25 25 255.0 5000 5 mL 50 1 to 0.01 to 0.001 to 0.001 to — — 0.0001 to 50 to q.s.to 500 500 25 25 5.0 5000 5 mL *Phosphate Buffer (monobasic/dibasicsodium salts), pH 6.2

TABLE 1-5 Ingredient and Amount Citrate Buffer (citric PropyleneCetylpyridinium Composition Pirfenidone acid/sodium citrate), EthanolGlycol Glycerol Polysorbate Bromide (or Osmolality no. (mg) pH 3.5 to pH6.5 (% v/v) (% v/v) (% v/v) 80 (% v/v) chloride) (%) (mOsmo/kg) Water 511 to 0.01 to 0.001 to — — — — 50 to q.s. to 500 500 25 5000 5 mL 52 1 to0.01 to — 0.001 to — — — 50 to q.s. to 500 500 25 5000 5 mL 53 1 to 0.01to — — 0.001 to — — 50 to q.s. to 500 500 25 5000 5 mL 54 1 to 0.01 to —— — 0.0001 to — 50 to q.s. to 500 500 1.0 5000 5 mL 55 1 to 0.01 to — —— — 0.0001 to 50 to q.s. to 500 500 5.0 5000 5 mL 56 1 to 0.01 to 0.001to 0.001 to — — — 50 to q.s. to 500 500 25 25 5000 5 mL 57 1 to 0.01 to0.001 to — 0.001 to — — 50 to q.s. to 500 500 25 25 5000 5 mL 58 1 to0.01 to 0.001 — — 0.0001 to — 50 to q.s. to 500 500 to 25 1.0 5000 5 mL59 1 to 0.01 to 0.001 to — — — 0.0001 to 50 to q.s. to 500 500 25 5.05000 5 mL 60 1 to 0.01 to 0.001 to 0.001 to 0.001 to — — 50 to q.s. to500 500 25 25 25 5000 5 mL 61 1 to 0.01 to 0.001 to 0.001 to — 0.0001 to— 50 to q.s. to 500 500 25 25 1.0 5000 5 mL 62 1 to 0.01 to 0.001 to0.001 to — — 0.0001 to 50 to q.s. to 500 500 25 25 5.0 5000 5 mL 63 1 to0.01 to 0.001 to 0.001 to 0.001 to 0.0001 to — 50 to q.s. to 500 500 2525 25 1.0 5000 5 mL 64 1 to 0.01 to 0.001 to 0.001 to — 0.0001 to — 50to q.s. to 500 500 25 25 1.0 5000 5 mL 65 1 to 0.01 to 0.001 to 0.001 to0.001 to — 0.0001 to 50 to q.s. to 500 500 25 25 25 5.0 5000 5 mL 66 1to 0.01 to 0.001 to 0.001 to — — 0.0001 to 50 to q.s. to 500 500 25 255.0 5000 5 mL

TABLE 1-6 Ingredient and Amount Phosphate Buffer Chloride ion(monobasic/ (sodium, Compo- dibasic sodium Propylene Cetylpyridiniummagnesium sition Pirfenidone salts), pH 5.5 Ethanol Glycol GlycerolPolysorbate Bromide (or or calcium Osmolality no. (mg) to 8.5 (mM) (%v/v) (% v/v) (% v/v) 80 (%) chloride) (%) salts) (%) (mOsmo/kg) Water 671 to 0.01 to 0.001 to — — — — 0.01 to 50 to q.s. to 500 500 25 5 5000 5mL  68* 1 to 0.01 to — 0.001 to — — — 0.01 to 50 to q.s. to 500 500 25 55000 5 mL 69 1 to 0.01 to — — 0.001 to — — 0.01 to 50 to q.s. to 500 50025 5 5000 5 mL 70 1 to 0.01 to — — — 0.0001 to — 0.01 to 50 to q.s. to500 500 1.0 5 5000 5 mL  71* 1 to 0.01 to — — — — 0.0001 to 0.01 to 50to q.s. to 500 500 5.0 5 5000 5 mL 72 1 to 0.01 to 0.001 to 0.001 to — —— 0.01 to 50 to q.s. to 500 500 25 25 5 5000 5 mL 73 1 to 0.01 to 0.001to — 0.001 to — — 0.01 to 50 to q.s. to 500 500 25 25 5 5000 5 mL 74 1to 0.01 to 0.001 to — — 0.0001 to — 0.01 to 50 to q.s. to 500 500 25 1.05 5000 5 mL 75 1 to 0.01 to 0.001 to — — — 0.0001 to 0.01 to 50 to q.s.to 500 500 25 5.0 5 5000 5 mL 76 1 to 0.01 to 0.001 to 0.001 to 0.001 to— — 0.01 to 50 to q.s. to 500 500 25 25 25 5 5000 5 mL 77 1 to 0.01 to0.001 to 0.001 to — 0.0001 to — 0.01 to 50 to q.s. to 500 500 25 25 1.05 5000 5 mL 78 1 to 0.01 to 0.001 to 0.001 to — — 0.0001 to 0.01 to 50to q.s. to 500 500 25 25 5.0 5 5000 5 mL 79 1 to 0.01 to 0.001 to 0.001to 0.001 to 0.0001 to — 0.01 to 50 to q.s. to 500 500 25 25 25 1.0 55000 5 mL 80 1 to 0.01 to 0.001 to 0.001 to — 0.0001 to — 0.01 to 50 toq.s. to 500 500 25 25 1.0 5 5000 5 mL 81 1 to 0.01 to 0.001 to 0.001 to0.001 to — 0.0001 to 0.01 to 50 to q.s. to 500 500 25 25 25 5.0 5 5000 5mL 82 1 to 0.01 to 0.001 to 0.001 to — — 0.0001 to 0.01 to 50 to q.s. to500 500 25 25 5.0 5 5000 5 mL *Phosphate Buffer (monobasic/dibasicsodium salts), pH 6.2

TABLE 1-7 Ingredient and Amount Citrate Buffer Chloride ion (citricacid/ (sodium, Compo- sodium citrate), Propylene Cetylpyridiniummagnesium sition Pirfenidone pH 3.5 to pH Ethanol Glycol GlycerolPolysorbate Bromide (or or calcium Osmolality no. (mg) 6.5 (mM) (% v/v)(% v/v) (% v/v) 80 (%) chloride) (%) salts) (%) (mOsmo/kg) Water 83 1 to0.01 to 0.001 to — — — — 0.01 to 50 to q.s. to 500 500 25 5 5000 5 mL 841 to 0.01 to — 0.001 to — — — 0.01 to 50 to q.s. to 500 500 25 5 5000 5mL 85 1 to 0.01 to — — 0.001 to — — 0.01 to 50 to q.s. to 500 500 25 55000 5 mL 86 1 to 0.01 to — — — 0.0001 to — 0.01% to 50 to q.s. to 500500 1.0 5% 5000 5 mL 87 1 to 0.01 to — — — — 0.0001 to 0.01 to 50 toq.s. to 500 500 5.0 5 5000 5 mL 88 1 to 0.01 to 0.001 to 0.001 to — — —0.01 to 50 to q.s. to 500 500 25 25 5 5000 5 mL 89 1 to 0.01 to 0.001 to— 0.001 to — — 0.01 to 50 to q.s. to 500 500 25 25 5 5000 5 mL 90 1 to0.01 to 0.001 to — — 0.0001 to — 0.01 to 50 to q.s. to 500 500 25 1.0 55000 5 mL 91 1 to 0.01 to 0.001 to — — — 0.0001 to 0.01 to 50 to q.s. to500 500 25 5.0 5 5000 5 mL 92 1 to 0.01 to 0.001 to 0.001 to 0.001 to —— 0.01 to 50 to q.s. to 500 500 25 25 25 5 5000 5 mL 93 1 to 0.01 to0.001 to 0.001 to — 0.0001 to — 0.01 to 50 to q.s. to 500 500 25 25 1.05 5000 5 mL 94 1 to 0.01 to 0.001 to 0.001 to — — 0.0001 to 0.01 to 50to q.s. to 500 500 25 25 5.0 5 5000 5 mL 95 1 to 0.01 to 0.001 to 0.001to 0.001 to 0.0001 to — 0.01 to 50 to q.s. to 500 500 25 25 25 1.0 55000 5 mL 96 1 to 0.01 to 0.001 to 0.001 to — 0.0001 to — 0.01 to 50 toq.s. to 500 500 25 25 1.0 5 5000 5 mL 97 1 to 0.01 to 0.001 to 0.001 to0.001 to — 0.0001 to 0.01 to 50 to q.s. to 500 500 25 25 25 5.0 5 5000 5mL 98 1 to 0.01 to 0.001 to 0.001 to — — 0.0001 to 0.01 to 50 to q.s. to500 500 25 25 5.0 5 5000 5 mL

TABLE 1-8 Ingredient and Amount Citrate Buffer (citric acid/ sodiumcitrate), Propylene Composition Pirfenidone pH 4.0 to pH Ethanol GlycolOsmolality no. (mg) 5.0 (mM) (% v/v) (% v/v) (mOsmo/kg) Water 99 5 mg(27 5 0.5% 1.0% 200 to q.s. to μmols) 400 5 mL 100 5 mg (27 5 1.0% 2.0%400 to q.s. to μmols) 600 5 mL 101 10 mg (54 5 1.0% 2.0% 400 to q.s. toμmols) 600 5 mL 102 15 (81 5 1.0% 2.0% 400 to q.s. to μmols) 600 5 mL103 25 mg (135 5 1.0% 2.0% 400 to q.s. to μmols) 600 5 mL 104 37.5 mg(202 5 1.0% 2.0% 400 to q.s. to μmols) 600 5 mL 105 75 mg (405 5 1.0%2.0% 400 to q.s. to μmols) 600 5 mL 106 100 mg (541 5 2.0% 4.0% 900 toq.s. to μmols) 1100 5 mL 107 115 mg (621 5 4.0% 8.0% 1800 to q.s. toμmols) 2100 5 mL 108 150 mg (810 5 6.0% 12.0% 1800 to q.s. to μmols)2100 5 mL 109 190 mg (1027 5 8.0% 16.0% 3500 to q.s. to μmols) 3900 5 mL110 220 mg (1189 5 8.0% 16.0% 3600 to q.s. to μmols) 4000 5 mL

TABLE 1-9 Ingredient and Amount Phosphate Buffer (monobasic/dibasicsodium salts), pH Propylene Composition Pirfenidone 6.0 to pH 7.0Ethanol Glycol Osmolality no. (mg) (mM) (% v/v) (% v/v) (mOsmo/kg) Water111 5 mg (27 5 0.5% 1.0% 200 to q.s. to μmols) 400 5 mL 112 5 mg (27 51.0% 2.0% 200 to q.s. to μmols) 600 5 mL 113 10 mg (54 5 1.0% 2.0% 400to q.s. to μmols) 600 5 mL 114 15 (81 5 1.0% 2.0% 400 to q.s. to μmols)600 5 mL 115 25 mg (135 5 1.0% 2.0% 400 to q.s. to μmols) 600 5 mL 11637.5 mg (202 5 1.0% 2.0% 400 to q.s. to μmols) 600 5 mL 117 75 mg (405 51.0% 2.0% 400 to q.s. to μmols) 600 5 mL 118 100 mg (541 5 2.0% 4.0% 900to q.s. to μmols) 1100 5 mL 119 115 mg (621 5 4.0% 8.0% 1800 to q.s. toμmols) 2100 5 mL 120 150 mg (810 5 6.0% 12.0% 1800 to q.s. to μmols)2100 5 mL 121 190 mg (1027 5 8.0% 16.0% 3500 to q.s. to μmols) 3900 5 mL122 220 mg (1189 5 8.0% 16.0% 3600 to q.s. to μmols) 4000 5 mL

TABLE 1-10 Ingredient and Amount Citrate Buffer (citric acid/ Chlorideion sodium citrate), Propylene (sodium, Composition Pirfenidone pH 4.0to pH 5.0 Ethanol Glycol magnesium or Osmolality no. (mg) (mM) (% v/v)(% v/v) calcium salts) (mOsmo/kg) Water 123 5 mg (27 5 0.5% 1.0% 0.1% to200 to q.s. to μmols) 0.9% 500 5 mL 124 5 mg (27 5 1.0% 2.0% 0.1% to 400to q.s. to μmols) 0.9% 700 5 mL 125 10 mg (54 5 1.0% 2.0% 0.1% to 400 toq.s. to μmols) 0.9% 700 5 mL 126 15 (81 5 1.0% 2.0% 0.1% to 400 to q.s.to μmols) 0.9% 700 5 mL 127 25 mg (135 5 1.0% 2.0% 0.1% to 400 to q.s.to μmols) 0.9% 700 5 mL 128 37.5 mg (202 5 1.0% 2.0% 0.1% to 400 to q.s.to μmols) 0.9% 700 5 mL 129 75 mg (405 5 1.0% 2.0% 0.1% to 400 to q.s.to μmols) 0.9% 700 5 mL 130 100 mg (541 5 2.0% 4.0% 0.1% to 900 to q.s.to μmols) 0.9% 1200 5 mL 131 115 mg (621 5 4.0% 8.0% 0.1% to 1800 toq.s. to μmols) 0.9% 2200 5 mL 132 150 mg (810 5 6.0% 12.0% 0.1% to 1800to q.s. to μmols) 0.9% 2200 5 mL 133 190 mg (1027 5 8.0% 16.0% 0.1% to3500 to q.s. to μmols) 0.9% 4000 5 mL 134 220 mg (1189 5 8.0% 16.0% 0.1%to 3600 to q.s. to μmols) 0.9% 4100 5 mL

TABLE 1-11 Ingredient and Amount Phosphate Buffer (monobasic/dibasicChloride ion sodium salts), (sodium, Composition Pirfenidone pH 6.0 topH 7.0 Propylene magnesium or Osmolality no. (mg) (mM) Ethanol Glycolcalcium salts) (mOsmo/kg) Water 135 5 mg (27 5 0.5% 1.0% 0.1% to 200 toq.s. to μmols) 0.9% 500 5 mL 136 5 mg (27 5 1.0% 2.0% 0.1% to 200 toq.s. to μmols) 0.9% 700 5 mL 137 10 mg (54 5 1.0% 2.0% 0.1% to 400 toq.s. to μmols) 0.9% 700 5 mL 138 15 (81 5 1.0% 2.0% 0.1% to 400 to q.s.to μmols) 0.9% 700 5 mL 139 25 mg (135 5 1.0% 2.0% 0.1% to 400 to q.s.to μmols) 0.9% 700 5 mL 140 37.5 mg (202 5 1.0% 2.0% 0.1% to 400 to q.s.to μmols) 0.9% 700 5 mL 141 75 mg (405 5 1.0% 2.0% — 400 to q.s. toμmols) 700 5 mL 142 100 mg (541 5 2.0% 4.0% 0.1% to 900 to q.s. toμmols) 0.9% 1200 5 mL 143 115 mg (621 5 4.0% 8.0% 0.1% to 1800 to q.s.to μmols) 0.9% 2200 5 mL 144 150 mg (810 5 6.0% 12.0% 0.1% to 1800 toq.s. to μmols) 0.9% 2200 5 mL 145 190 mg (1027 5 8.0% 16.0% 0.1% to 3500to q.s. to μmols) 0.9% 4000 5 mL 146 220 mg (1189 5 8.0% 16.0% 0.1% to3600 to q.s. to μmols) 0.9% 4100 5 mL

Example 2: Buffer and pH Effects Development Study

Pirfenidone solubility in citrate and phosphate buffers wereinvestigated (Table 2). Pirfenidone (250 mg) was reconstituted with 5 mLof buffer in water or water alone and mixed thoroughly with sonicationand vortexing. The sample was agitated at ambient temperature overnight.The sample was visually inspected, appearance recorded, centrifuged tosediment any un-dissolved material, and the supernatant withdrawn viasyringe through a 0.22 μm PVDF filter. The filtered sample was testedwith respect to: appearance, pH (USP <791>), osmolality (USP <785>), andPirfenidone concentration and Pirfenidone % purity by RP-HPLC. Theremaining filtered sample was split into three equal volumes in glassvials and placed at 25° C./60 RH, 40° C./75 RH and refrigeration.Samples were wrapped in aluminum foil to reduce light exposure. Afterthe first night of incubation, samples were briefly visually inspectedfor any signs of discoloration or precipitate formation.

TABLE 2 Buffer/pH Effects Study Results Buffer Pirfenidone SaturationBuffer (mM) pH Solubility (mg/mL) Citrate 5 4 18.4 Citrate 50 4 18.1Citrate 5 6 18.4 Citrate 50 6 16.4 Phosphate 5 6 18.3 Phosphate 50 617.2 Phosphate 5 7.5 19.0 Phosphate 50 7.5 16.3 Water 0 7.9 18.4

Table 2 shows the observed solubility of pirfenidone under theconditions described.

Example 3: Co-Solvent and Surfactant Effects

Pirfenidone solubility in the presence of added co-solvent (ethanol,propylene glycol, or glycerin) and surfactant (polysorbate 80 orcetylpyridinium bromide) were investigated. The buffer type, strength,and pH of the aqueous vehicle are selected based on results from theBuffer/pH Effects study results (Example 2). Pirfenidone (375 mg) isreconstituted with 5 mL of each solvent system shown in Table 3.

TABLE 3 Co-Solvent/Surfactant Effects Study Results % % PirfenidoneCitrate Phosphate Saturation Added Co-Solvent and/or Surfactant, % %Buffer Buffer Solubility EtOH PG Gly PS80 CPB Water (10 mM) (5 mM) pH(mg/mL) 0 0 0 0.04 0 100.0 0 0 6.5 19.9 0 0 0 0 0.1 99.9 0 0 6.2 20.0 00 0 0.04 0 100.0 0 0 4.8  8.3 0 0 0 0 0.1 99.9 0 0 4.6 19.3 0 0 0 0.04 00 100.0 0 4.5 19.1 0 0 0 0 0.1 0 99.9 0 4.5 19.3 4 0 0 0 0 96.0 0 0 6.924.3 0 8 0 0 0 92.0 0 0 6.8 24.6 0 0 4 0 0 96.0 0 0 6.7 20.1 4 0 0 0 096.0 0 0 5.0 22.8 0 8 0 0 0 92.0 0 0 5.0 24.3 0 0 4 0 0 96.0 0 0 4.820.1 4 0 0 0 0 0 96.0 0 4.5 22.3 0 8 0 0 0 0 92.0 0 4.4 23.2 0 0 4 0 0 096.0 0 4.4 19.8 4 0 0 0.04 0 96.0 0 0 6.7 24.5 0 8 0 0.04 0 92.0 0 0 6.623.2 0 0 4 0.04 0 96.0 0 0 6.5 20.2 4 0 0 0.04 0 96.0 0 0 4.7 22.5 0 8 00.04 0 92.0 0 0 4.6 23.4 0 0 4 0.04 0 96.0 0 0 4.9 20.0 4 0 0 0.04 0 096.0 0 4.5 21.9 0 8 0 0.04 0 0 92.0 0 4.5 23.2 0 0 4 0.04 0 0 96.0 0 4.417.6 4 0 0 0 0.1 95.9 0 0 6.1 23.9 0 8 0 0 0.1 91.9 0 0 6.2 23.4 0 0 4 00.1 95.9 0 0 ND ND 4 0 0 0 0.1 95.9 0 0 4.9 20.2 0 8 0 0 0.1 91.9 0 05.0 22.3 0 0 4 0 0.1 95.9 0 0 ND ND 4 0 0 0 0.1 0 95.9 0 4.5 20.4 0 8 00 0.1 0 91.9 0 4.5 21.0 0 0 4 0 0.1 0 95.9 0 ND ND 4 8 0 0 0 88.0 0 06.2 30.0 4 8 0 0.04 0 88.0 0 0 5.8 28.9 4 8 0 0 0 0 0 88.0 6.6 27.2 4 80 0.04 0 0 0 88.0 6.6 29.4 6 12 0 0 0 0 0 82.0 7.0 34.7 8 16 0 0 0 0 076.0 7.0 43.7 8 0 0 0 0 0 0 92 6.6 26.7 8 4 0 0 0 0 0 88 6.8 30.4 8 8 00 0 0 0 84 6.8 35.0 8 12 0 0 0 0 0 80 6.7 37.7 8 16 0 0 0 0 0 76 6.845.4 6 16 0 0 0 0 0 78 6.9 40.9 4 16 0 0 0 0 0 80 6.9 36.8 2 16 0 0 0 00 82 6.8 31.0 0 16 0 0 0 0 0 84 6.8 29.3 * Buffer type, buffer strength,and pH chosen on the basis of Buffer/pH study results (Example 2). EtOH:ethanol, PG: propylene glycol, Gly: glycerol, PS80: polysorbate 80(Tween 80), CPB: Cetylpyridinium chloride. % in Table 3 refers tovolume/volume.

Each sample was agitated at ambient temperature overnight. The sampleswere visually inspected and appearance recorded. Samples werecentrifuged to sediment any un-dissolved material and the supernatantwithdrawn via syringe through a 0.22 μm PVDF filter. The filtered samplewas tested with respect to: appearance, pH (USP <791>), osmolality (USP<785>), and Pirfenidone concentration and Pirfenidone % purity byRP-HPLC. The remaining filtered sample was split into three equalvolumes in glass vials and placed at 25° C./60 RH, 40° C./75 RH andrefrigeration. Samples are wrapped in aluminum foil to reduce lightexposure. After the first night of incubation, samples are brieflyvisually inspected for any signs of discoloration or precipitateformation.

Both ethanol (EtOH) and propylene glycol (PG) increase the saturationsolubility of pirfenidone. Ethanol and propylene glycol together have anadditive effect in increasing the saturation solubility of pirfenidone.

Selected formulations were subjected to osmolality determination andnebulization for taste testing and throat irritation and or coughresponse. Table 4 shows these results.

TABLE 4 Compositions and Additional Analysis Added Co-Solvent % and/orSurfactant Sodium Phosphate (%)^(a) Saccharin Buffer PirfenidoneOsmolality Throat Cough EtOH PG (mM) (5 mM) pH (mg/mL) (mOsmo/Kg) TasteIrritation? Response? 4 8 0 88 6.6 27.2 ~1830* 4.5 micron aerosol No Noparticle: Mild taste, unremarkable flavor 6 12 0 82 7.0 34.7 ~2750* 4.5micron aerosol No No particle: Mild taste, slight sweet flavor, slightbitter after-taste 8 16 0 76 7.0 43.7 3672 4.5 micron aerosol No Noparticle: Mild taste, moderate sweet flavor, moderate bitter after-taste3.5 micron aerosol particle: Mild taste, similar sweet flavor and bitterafter-taste as 6% EtOH + 12% PG 8 16 0.3 76 7.0 43.7 3672 3.5 micronaerosol No No particle: Mild taste, similar sweet flavor and slightlybitter after-taste similar to 6% EtOH + 12% PG 8 16 0 76 4.5 0 3672 3.5micron aerosol No No particle: Mild taste, slightly sweeter than 6%EtOH + 12% PG, with similar bitter after-taste *Calculated. ^(a)%volume/volume

Results from Table 4 show that co-solvent-containing formulationscontain a relatively high osmolality. Unexpectedly, these high osmolarsolutions do not exhibit poor inhalation tolerability. Solutionscontaining up to 8% (v/v) ethanol plus 16% (v/v) propylene glycol arewell-tolerated, have a slight sweet flavor with minimal bitterafter-taste, minimal throat irritation and minimal stimulation of coughresponse. Formulations lacking co-solvents are limited to about 15mg/mL. These same formulations exhibited a bitter, slightly metallictaste. Unexpectedly, co-solvent-enabling high concentration pirfenidoneformulations (by non-limiting example up to 44 mg/mL) do not exhibitthese poor taste characteristics.

Saturated pirfenidone formulations appeared stable out to 2-5 days underthe tested conditions. However, in all cases pirfenidone eventuallyre-crystallized. This re-crystallization was not inhibited bypre-filtration of the sample. From this observation, pirfenidoneconcentrations less then saturation were explored. 85% saturationpirfenidone concentrations were exposed to several temperatures. Theseresults are shown in Table 5.

TABLE 5 Compositions and Additional Analysis % Phos- Recrystallizationupon Added Co- phate storage^(a) Solvent (%) Buffer Pirfenidone 25° 15°4° −20° EtOH PG (5 mM) pH (mg/mL) C. C. C. C. 4 8 88 6.6 27.2^(b) YesND^(d) ND ND 4 8 88 6.6 23.0^(e) No No No Yes^(f) 6 12 82 7.0 34.7 YesND ND ND 6 12 82 7.0 29.5 No No No Yes^(f) 8 16 76 7.0 43.7 Yes ND ND ND8 16 76 7.0 37.0 No No No Yes^(f) ^(a)Observation after overnightstorage at designated temperature ^(b)Pirfenidone saturation solubilityat given formulation c. Calculated ^(d)Not determined ^(e)Pirfenidoneconcentration at 85% saturation solubility ^(f)Crystals re-dissolved at25° C. without agitation % refers to % v/v

Results from Table 5 show that these 85% pirfenidone saturationformulations do not re-crystallize down to 4° C. (at least followingovernight incubation). These results suggest that these formulationswill survive periodic exposures down to 4° C., and even upon freezingwill re-dissolve without agitation.

Additional studies examined pirfenidone stability in 5 mM sodiumphosphate buffer, pH 6.5, as a function of optimized co-solvent strengthfor stability assessment. The target concentrations represent roughly85% of the saturated concentration possible at each specified co-solventconcentration. Two additional formulations examined pirfenidonestability at 1 mg/mL in specific formulations. Pirfenidone (amounts areoutlined in Table 6) was reconstituted with 100 mL vehicle as describedand mixed thoroughly by agitation. The sample was agitated untilcompletely dissolved. Once dissolved, samples were filtered via syringethrough a 0.22 μm PVDF filter.

Samples were refrigerated to reduce evaporative loss of volatileco-solvents (ethanol) during filtration and dispensing. An approximate5.0-mL aliquot of each formulation was transferred to class A glass 6 mlcontainers with suitable closures (20 mm stopper). At least 8 containersare being maintained in the upright orientation at 25° C./60 RH, andanother 8 containers maintained at 40° C./75 RH. One container for eachformulation was used for the initial evaluation, t=0, with testing for:appearance, pH, osmolality, HPLC=RP-HPLC for pirfenidone assay (reportedas % label claim) and individual impurities (reported as % pirfenidoneand RRT). Stability time point testing will evaluate for appearance, andHPLC=RP-HPLC for pirfenidone assay (reported as % label claim) andindividual impurities (reported as % pirfenidone and RRT).

TABLE 6 Representative Pirfenidone Formulations for Stability AssessmentTarget 5 mM Phosphate Target Add Add Add Add Buffer, pH 6.5, PirfenidonePirfenidone Buffer Ethanol PG plus (mg/mL) (mg) (mL) (mL) (mL) 8% (v/v)EtOH, 38 3800 20 8.0 16.0 16% (v/v) PG 8% (v/v) EtOH, 1 100 20 8.0 16.016% (v/v) PG 6% (v/v) EtOH, 30 300 20 6.0 12.0 12% (v/v) PG 4% (v/v)EtOH, 23 230 20 4.0 8.0 8% (v/v) PG 1% (v/v) EtOH, 15 150 20 1.0 2.0 2%(v/v) PG 1% (v/v) EtOH, 1 100 20 1.0 2.0 2% (v/v) PG

For each variant Formulation, samples are tested according to theschedule shown in Table 7.

TABLE 7 Stability Schedule Tests* Performed at Time Point (mo) = contin-Condition 0 0.5** 1 3 6 9 12 gency total 25° C./60% RH 1 1 1 1 1 1 1 2 940° C./75% RH 1 1 1 1 1 1 2 8 *all samples will be tested for appearanceby visual observation, pH, HPLC = RP-HPLC for pirfenidone assay(reported as % label claim), and individual impurities (reported as %pirfenidone and RRT). At t = 0, testing will also include osmolality.**Appearance only

TABLE 8a Time-Zero Stability Assessment Target 5 mM Phosphate TargetMeasured Buffer, pH 6.5, Pirfenidone Pirfenidone mOsmol/ plus (mg/mL)(mg/mL) pH kg App. 8% (v/v) EtOH, 38 38.9 7.04 3750 * 16% (v/v) PG 8%(v/v) EtOH, 1 1.0 6.98 3590 * 16% (v/v) PG 6% (v/v) EtOH, 30 30.3 6.902863 * 12% (v/v) PG 4% (v/v) EtOH, 23 24.1 6.78 1928 * 8% (v/v) PG 1%(v/v) EtOH, 15 16.1 6.65 512 * 2% (v/v) PG 1% (v/v) EtOH, 1 1.0 6.69452 * 2% (v/v) PG * All solutions are clear and colorless withoutvisible signs of crystallization.

TABLE 8b Pirfenidone Measurements at 25° C./60% RH Target 5 mMPirfenidone Pirfenidone Pirfenidone Phosphate Target Pirfenidone (mg/mL)(mg/mL) (mg/mL) Buffer, pH 6.5, Pirfenidone (mg/mL) at Time = at Time =at Time = plus (mg/mL) at Time = 0 1 month 3 month 6 month 8% (v/v)EtOH, 38 38.9 38.3 38.0 39.2 16% (v/v) PG 8% (v/v) EtOH, 1 1.0 1.0 1.01.0 16% (v/v) PG 6% (v/v) EtOH, 30 30.3 30.1 29.6 31.0 12% (v/v) PG 4%(v/v) EtOH, 23 24.1 22.1 22.3 23.2 8% (v/v) PG 1% (v/v) EtOH, 15 16.115.1 14.9 15.4 2% (v/v) PG 1% (v/v) EtOH, 1 1.0 1.0 1.0 1.0 2% (v/v)PG * All solutions are clear and colorless without visible signs ofcrystallization.

TABLE 8c Pirfenidone Measurements at 40° C./75% RH Target 5 mMPirfenidone Pirfenidone Pirfenidone Phosphate Target Pirfenidone (mg/mL)(mg/mL) (mg/mL) Buffer, pH 6.5, Pirfenidone (mg/mL) at Time = at Time =at Time = plus (mg/mL) at Time = 0 1 month 3 month 6 month 8% (v/v)EtOH, 38 38.9 38.4 38.0 37.9 16% (v/v) PG 8% (v/v) EtOH, 1 1.0 1.0 1.01.0 16% (v/v) PG 6% (v/v) EtOH, 30 30.3 30.3 30.0 31.1 12% (v/v) PG 4%(v/v) EtOH, 23 24.1 22.4 22.1 23.3 8% (v/v) PG 1% (v/v) EtOH, 15 16.115.1 14.8 15.5 2% (v/v) PG 1% (v/v) EtOH, 1 1.0 1.0 1.0 1.0 2% (v/v)PG * All solutions are clear and colorless without visible signs ofcrystallization.

Selected formulations were prepared for pharmacokinetic analysisfollowing aerosol delivery to rat lung. In these studies, lung, heart,kidney and plasma tissue samples were analyzed for pirfenidone andmetabolite content (Tables 16-19). Formulations prepared for this studyare outlined in Table 9. Briefly, this study prepared pirfenidone in 5mM sodium phosphate buffer, pH 6.5, as a function of optimizedco-solvent strength. The target concentration in each formulation is12.5 mg/mL. Pirfenidone (amounts as described in Table 9) werereconstituted with 30 mL vehicle as described and mixed thoroughly byagitation. The sample was agitated until completely dissolved. Oncepirfenidone had dissolved completely, formulations were filtered viasyringe through a 0.22 μm PVDF filter. Filtered samples were analyzed byHPLC.

The samples were then refrigerated to reduce evaporative loss ofvolatile co-solvents (ethanol) during filtration and dispensing.Formulations were transferred to class A glass containers (approximately10 mL) with suitable closures (20 mm stopper).

TABLE 9 Formulations for Co-Solvent Effects Pharmacokinetic and TissueDistribution Study Target 5 mM Phosphate Target Add Add Add Add AddDosing Buffer, pH Vol. Pirfenidone Pirfenidone Buffer** EtOH PG NaClGroup 6.5, plus (mL)* (mg/mL) (mg) (mL) (mL) (mL) (g) 1 8% (v/v) 30 12.5375 6 2.4 4.8 0 EtOH, 16% (v/v) PG 2 6% (v/v) 30 12.5 375 6 1.8 3.6 0EtOH, 12% (v/v) PG 3 4% (v/v) 30 12.5 375 6 1.2 2.4 0 EtOH, 8% (v/v) PG4 2% (v/v) 30 12.5 375 6 0.6 1.2 0 EtOH, 4% (v/v) PG 5 1% (v/v) 30 12.5375 6 0.3 0.6 0 EtOH, 2% (v/v) PG 6 0.4% NaCl 30 12.5 375 6 0 0 0.12*Pirfenidone was reconstituted with 30 mL of the indicated Vehicle byQS'ing the remaining volume with water. **25 mM NaPO4, pH 6.5 (5Xsolution)

Example 4: Nebulization Device Performance

Selected formulations were prepared for nebulization device aerosolcharacterization. Briefly, this study prepared pirfenidone in 5 mMsodium phosphate buffer, pH 6.5, as a function of optimized co-solventstrength. These formulations are outlined in Table 10. Pirfenidone(amounts as listed in Table 10) were reconstituted as described andmixed thoroughly by agitation. Each sample was agitated until completelydissolved. Once dissolved completely, formulations were filtered viasyringe through a 0.45 μm PVDF filter. Filtered samples were analyzed byHPLC.

Each sample was refrigerated to reduce evaporative loss of volatileco-solvents (ethanol) during filtration and dispensing. As described inTable 10, each formulation was transferred to class A glass containerswith suitable closures.

TABLE 10 Formulations for Nebulization Device Aerosol PerformanceStudies Target 5 mM Phosphate Target Add Add Add Add Add Test Buffer, pHVol. Pirfenidone Pirfenidone Buffer* Ethanol PG NaCl Article 6.5, plus(mL) (mg/mL) (mg) (mL) (mL) (mL) (g) 1 8% (v/v) 200  38** 7600 40 16 320 EtOH, 16% (v/v) PG 2 8% (v/v) 200 0 0 40 16 32 0 EtOH, 16% (v/v) PG 31% (v/v) 200 0 0 40 2 4 0 EtOH, 2% (v/v) PG 4 0.2% (v/v) NA    0.475Diluted Test Articles 1 and 3 EtOH, 0.4% (v/v) PG 5 0.4% NaCl 200 0 0 400 0 0.8 *25 mM NaPO4, pH 6.5 (5X solution) **Active formulations werediluted with water and vehicle by the device characterization facilityas necessary to characterize lower pirfenidone concentrations.

Philips I-Neb® AAD System

For aerosol analysis, three units of each I-neb breath-actuatednebulizer were studied in triplicate for each device/formulationcombination. Using Malvern Mastersizer aerosol particle sizer, theparticle size and distribution was characterized. Parameters reportedwere mass median diameter (MMD), span, fine particle fraction (FPF=% ≤5microns), output rate (mg formulation per second), nebulized volume,delivered volume (volume of dose in range of FPF), respirable delivereddose (mg pirfenidone delivered volume). Aerosol output was measuredusing a 5 second inhalation, 2 second exhalation breathing pattern witha 1.25 L tidal volume. The results are shown in Table 11.

TABLE 11 Nebulization of Pirfenidone Formulations using the PhilipsI-neb Device Test Test Test Test Test Article Article Article ArticleArticle Parameter 1 2 3 4 5 MMD (micron) 3.31 3.64 4.95 5.52 4.95 Span(micron) 1.13 1.36 1.21 1.14 1.20 FPF (% < 5 microns) 84.41 74.70 51.4042.01 51.11 Output rate (mg/sec) 0.96 1.31 3.52 6.92 4.60 Nebulized vol(mg) 776.63 810.42 846.42 853.30 814.51 Delivered vol (mg) 653.44 605.83436.19 345.55 417.12 RDD (mg)* 24.83 NA NA 0.16 NA *Exemplary (RDD = FPF× Nebulized Volume × loaded dose)

PARI eFlow®—35 Head

For aerosol analysis, three units of each eFlow nebulizer containing a35-head were studied in duplicate for each device/formulationcombination. Using an Insitec Spraytec Laser Particle sizer, theparticle size and distribution was characterized. Parameters reportedwere volumetric mean diameter (VMD), geometric standard deviation (GSD),time to nebulize dose (duration), remaining dose following nebulization(dead volume), and fine particle fraction (FPF=% ≤5 microns). 4 mL ofeach formulation was tested. The results are shown in Table 12.

TABLE 12 Nebulization of Pirfenidone Formulations using the PARI eFlowDevice Test Test Test Test Test Article Article Article Article ArticleParameter 1 2 3 4 5 Loaded Dose (mg) 152 0 0 1.9 0 VMD (micron) 2.602.84 3.60 3.88 3.81 GSD (micron) 1.86 1.85 1.74 1.68 1.68 FPF (% < 5microns) 85.47 81.81 71.26 67.70 68.78 Duration (min) 9.87 8.85 6.265.99 5.86 Dead volume (mL) 0.15 0.16 0.19 0.18 0.16 Output rate (mL/min)0.40 0.44 0.61 0.64 0.67 Nebulized vol (mL) 3.85 3.84 3.81 3.82 3.84 RDD(mg)* 87.04 NA NA 0.86 NA RDD (mg)/minute 8.82 NA NA 0.14 NA *Exemplary(RDD = FPF × Inhaled Mass × Loaded Dose). For the exemplary calculation,assume a 67% delivered dose (i.e. inhaled mass). (Representative of a1:1 inhalation:exhalation breathing pattern using the eFlow device with35 head.)

Aerogen Aeroneb® Solo

For aerosol analysis, between two and four units of each Aeroneb® Solonebulizer with Aeroneb® Pro-X controller were studied with eachformulation. Using a Malvern Spraytech aerosol particle sizer, theparticle size and distribution were characterized. Parameters reportedwere volumetric mean diameter (VMD), geometric standard deviation (GSD),time to nebulize dose (duration), remaining dose following nebulization(dead volume), and fine particle fraction (FPF=% ≤5 microns). 1 mL ofeach formulation was tested. The results are shown in Table 13.

TABLE 13 Nebulization of Pirfenidone Formulations using the Aeroneb SoloDevice Test Test Test Test Parameter Article 1 Article 2 Article 3Article 5 Loaded Dose (mg) 38 0 0 0 VMD (micron) 9.73 5.49 4.31 4.76 GSD(micron) 3.21 3.43 2.25 2.23 FPF (% < 5 microns) 38.97 48.13 59.09 53.77Duration (min) 5.88 5.56 4.17 2.17 Output rate (mL/min) 0.17 0.18 0.240.46 RDD (mg)* 9.9 NA NA NA RDD (mg)*/minute 1.68 NA NA NA *Exemplary(RDD = FPF × Inhaled Mass × Loaded Dose). For the exemplary calculation,assume a 67% inhaled mass.

Example 5: Process Temperature Development Study

This study examined the above-ambient temperature stability ofpirfenidone in aqueous solution to best understand stability at thistemperature and saturation solubility. This information may be utilizedwith manufacturing process embodiments of the present invention whereinhigh temperature pirfenidone aqueous dissolution, in the presence of orfollowed by co-solvent and/or surfactant and/or cation addition, andsubsequent cooling to ambient temperature provide higher pirfenidonesaturation solubility then ambient temperature dissolution alone. Inthis process, added co-solvent and/or surfactant and/or cation maystabilize the high-temperature-dissolved pirfenidone during the coolingprocess and provide a stable, high-concentration, ambient-temperatureformulation for long-term storage. Alternatively, the added co-solventand/or surfactant and/or cation may provide access to greater solublepirfenidone for which to maintain in solution then ambient temperaturedissolution alone. Alternatively, high-temperature dissolution may beintegrated into manufacturing process embodiments to reduce dissolutiontime and/or reduce the effects of lot-to-lot crystal structure, amorphiccontent and polymorph variability on dissolution time and degree ofdissolution.

Formulations were prepared as described in Table 11. Briefly, this studyprepared 250 mg pirfenidone in 5 mM sodium phosphate buffer, pH 6.5, inthe presence of ethanol, propylene glycol and/or polysorbate 80. Thefinal volume of each formulation was 5 mL. Pirfenidone (amounts aslisted in Table 11) were reconstituted as described and mixed thoroughlyby agitation. Each sample was mixed thoroughly and agitated overnight at60° C. Rapid cooling and step-wise cooling from 60° C. to 25° C. wasperformed. HPLC analysis was performed on samples taken after overnightincubation and after cooling to 25° C. Prior to HPLC analysis,formulations were filtered via syringe through a 0.45 μm PVDF filter.Results for this evaluation are shown in Table 14.

TABLE 14 Formulations for Process Temperature Study Added Co-SolventPirfenidone and/or Surfactant (mg/mL) (% v/v) % Phosphate >Re- EtOH PGPS80 Buffer (5 mM) pH >60° C.^(a) crystal^(b) Observations 4 8 0 88 6.750.34 27.6 Fully dissolved after overnight at 60° C. Stable at 25° C.for >4 hours before re-crystallization 4 8 0.04 88 6.7 51.8 26.8 Fullydissolved after overnight at 60° C. Stable at 25° C. for >4 hours beforere-crystallization 4 0 0.04 96 6.6 50.7 22.4 Fully dissolved afterovernight at 60° C. Stable at 25° C. for >4 hours beforere-crystallization 0 8 0.04 92 6.7 52.8 22.3 Fully dissolved afterovernight at 60° C. Stable at 25° C. for >4 hours beforere-crystallization 0 8 0 92 6.6 54.6 18.6 Fully dissolved afterovernight at 60° C. Stable at 25° C. for >4 hours beforere-crystallization ^(a)Pirfenidone assay content after stepwise coolingto 25° C. ^(b)Pirfenidone assay content after stepwise cooling to 25° C.and then later re-crystallization c. Calculated d. Not determined e.Pirfenidone concentration at 85% saturation solubility f. Crystalsre-dissolved at 25° C. without agitation

The results in Table 14 show that heating pirfenidone to 60° C. enablesfull dissolution up to or potentially greater than 50 mg/mL. Rapidcooling to 25° C. of this dissolved material led to rapidrecrystallization (data not shown). Slow cooling to 25° C. (step-wisefrom 60° C. to 40° C. to 30° C. then 25° C., with temperatureequilibration occurring at each step prior to further reducing thetemperature) enabled pirfenidone to stay in solution at about 50 mg/mLfor several hours before each solution ultimately re-crystallized.Filtering each formulation prior to re-crystallization (either at 30° C.or after equilibrium at 25° C.) did not noticeably extend or preventre-crystallization. Pirfenidone dissolution time is reduced by heatingand appears to be stable at this temperature during the dissolutionprocess. Thus, heating pirfenidone formulations can be beneficial in amanufacturing process embodiments to overcome the slower dissolutionobserved at ambient temperature.

Example 6: Pharmacokinetics and Lung-Tissue Distribution

Sprague-Dawley rats (300-350 grams) were administered pirfenidone byeither the oral (gavage) or aerosol (intratracheal Penn CenturyMicroSprayer® nebulizing catheter) routes. For oral administration, 50mg pirfenidone was dissolved in 3.33 mL distilled water containing 0.5%CMC to a final concentration of 15 mg/mL. Solutions were vortexed untilall crystals dissolved. Rats were administered 70 mg/kg pirfenidone(˜1.4 mL). Plasma samples were taken at pre-dose, 0.08, 0.16, 0.25, 0.5,0.75, 1.0, 1.5, 2, 4, and 6 hours post dosing. For lung tissue samples,eight additional rats were also dosed 70 mg/kg by the oral route. Lungswere taken at pre-dose 0.08, 0.5, 2, and 4 hours post dosing. Materialswere extracted and pirfenidone quantitated as μg/mL plasma and μg/gramlung tissue. For aerosol administration, 60 mg pirfenidone was dissolvedin 10 mM phosphate buffer, pH 6.2 containing 81 mM MgCl₂ (1:1pirfenidone to magnesium). Rats were administered 5 mg/kg pirfenidone(˜100 μL) by nebulizing catheter. Plasma samples were taken at pre-dose,0.08, 0.16, 0.25, 0.5, 0.75, 1.0, 1.5, 2, 4, and 6 hours post dosing.For lung tissue samples, eight additional rats were also dosed 70 mg/kgby the oral route. Lungs were taken at pre-dose 0.08, 0.5, 2, and 4hours post dosing. Materials were extracted and pirfenidone quantitatedas μg/mL plasma and μg/gram lung tissue. Results from these studies areshown in Table 15.

TABLE 15 Pirfenidone pharmacokinetics and tissue distribution followingoral and aerosol administration to rats. Aerosol Measured^(a) Oral Ratdose (mg/kg) 1 5 70 Lung Cmax^(b) 101 508 3.6 T_(1/2) ^(c) <1, 45 <1, 4545 AUC^(d) 5.2 25.4 4.3 TOE^(e) 5 84 89 Plasma Cmax^(f) 1.1 7.0 8.1T_(1/2) 30 30 30 AUC_(0-6 hrs) ^(g) 0.9 4.5 13.5 ^(a)Bolus aerosolintratracheal delivery ^(b)C_(max): Lung tissue (μg/g) immediatepost-dose calculated from the direct-lung delivered dose. All other timepoints measured. Plasma measured (μg/mL) ^(c)T_(1/2): Minutes (aerosol =α, β; oral = α only observed) ^(d)AUC: Lung tissue (mg · hr/kg fortime >1 μg/g) ^(e)TOE: Time of exposure as minutes over 1 μg/g lungtissue) ^(f)Cmax: Plasma (μg/mL) ^(g)AUC_(0-6 hrs): Plasma (mg · hr/L)

Example 7: Pharmacokinetics and Tissue Distribution of Co-SolventFormulations

To assess the pharmacokinetics and tissue distribution of co-solventformulations (described in Table 9), Sprague-Dawley rats (350-400 grams)in triplicate were administered pirfenidone by bolus aerosol(intratracheal Penn Century MicroSprayer® nebulizing catheter). Ratswere dosed about 4 mg/kg pirfenidone (˜150 μL) by nebulizing catheter.Plasma samples, and entire lungs, hearts and kidneys were taken atpre-dose, 0.033, 0.067, 0.1, 0.167, 0.333, 0.667, 1.0, 1.5, 2, and 2.5hours post dosing. Materials were extracted and pirfenidone quantitatedas μg/mL plasma and μg/gram lung, heart or kidney tissue. Results fromthese studies are shown in Table 16 thru 19. No adverse events werenoted in these studies.

TABLE 16 Pirfenidone Pharmacokinetics and Lung Tissue Distribution -Co-Solvent- Based Formulation Study (Dosing group formulations listed inTable 9) Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Time Mean MeanMean Mean Mean Mean Analyte (hr) μg/gram μg/gram μg/gram μg/gram μg/gramμg/gram PIRFENIDONE 0^(A) 393.72 0.0333 14.28 15.73 22.23 12.63 19.668.81 0.0667 10.40 8.53 17.26 7.77 10.70 7.93 0.1 7.53 5.98 7.34 7.505.83 6.83 0.167 5.36 5.71 6.16 5.23 8.78 5.17 0.333 4.15 3.79 3.79 3.664.70 3.83 0.667 2.09 2.41 2.43 2.40 1.91 2.28 1 1.53 1.24 1.03 1.20 1.441.22 1.5 0.60 0.71 0.46 0.67 0.48 0.37 2 0.26 0.35 0.32 0.21 0.26 0.312.5 0.08 0.13 0.13 0.10 0.07 0.22 5-CARBOXY-N- 0 MIN 0.00phenyl-5-1H-pyridone 0.0333 H 0.12 NOT TESTED 0.05 NOT TESTED 0.17 0.170.0667 H 0.13 0.36 0.42 0.43 0.100 H 0.48 0.55 0.35 0.37 0.167 H 0.490.86 0.53 0.64 0.333 H 0.96 1.09 1.32 0.94 0.667 H 0.96 0.81 0.96 0.92 1H 0.73 0.70 0.75 0.78 1.50 H 0.48 0.52 0.45 0.43 2 H 0.21 0.32 0.18 0.242.50 H 0.10 0.14 0.10 0.14 ^(A)Average of 18 immediate post-dosemeasurements

TABLE 17 Pirfenidone Plasma Pharmacokinetics - Co-Solvent-BasedFormulation Study (Dosing group formulations listed in Table 9) Group 1Group 2 Group 3 Group 4 Group 5 Group 6 Time Mean Mean Mean Mean MeanMean Analyte (hr) μg/mL μg/mL μg/mL μg/mL μg/mL μg/mL PIRFENIDONE 0 0.030.01 0.06 0.01 0.02 0.06 0.0333 6.80 6.20 7.47 7.23 7.72 6.84 0.06676.09 6.04 6.52 7.43 7.05 7.31 0.1 5.72 5.12 5.39 3.98 5.55 5.75 0.1675.56 5.60 5.51 4.75 4.59 5.31 0.333 3.94 4.53 4.53 3.98 3.84 4.26 0.6672.74 3.02 2.54 2.41 2.24 2.87 1 1.93 1.65 1.39 1.45 1.68 1.49 1.5 0.670.80 0.54 0.85 0.59 0.43 2 0.29 0.37 0.36 0.22 0.29 0.33 2.5 0.09 0.120.11 0.11 0.08 0.13

TABLE 18 Pirfenidone Pharmacokinetics and Heart Tissue Distribution -Co-Solvent- Based Formulation Study (Dosing group formulations listed inTable 9) Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Time Mean MeanMean Mean Mean Mean Analyte (hr) μg/gram μg/gram μg/gram μg/gram μg/gramμg/gram PIRFENIDONE 0 0.02 0.19 NOT TESTED 0.08 0.0667 7.90 5.92 6.320.167 4.91 4.10 4.95 0.333 3.85 3.13 3.43 0.667 1.80 2.19 2.22 1 1.401.10 1.23 1.5 0.60 0.69 0.35 2.5 0.09 0.12 0.12

TABLE 19 Pirfenidone Pharmacokinetics and Kidney Tissue Distribution -Co-Solvent- Based Formulation Study (Dosing group formulations listed inTable 9) Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Time Mean MeanMean Mean Mean Mean Analyte (hr) μg/gram μg/gram μg/gram μg/gram μg/gramμg/gram PIRFENIDONE 0 0.01 0.47 NOT TESTED 0.27 0.0667 9.88 10.79 12.900.167 6.62 8.30 6.65 0.333 4.87 7.44 4.87 0.667 2.86 3.31 3.53 1 1.931.75 1.71 1.5 0.95 0.96 0.57 2.5 0.21 0.18 0.20

Results from the co-solvent effects tissue distribution studies showthat the presence of up to 8% ethanol with 16% propylene glycol tochange the tissue or plasma pharmacokinetic profile compared to a 0.4%sodium chloride formulation. Further, these results show a delayedappearance of 5-Carboxy-pirfenidone (the primary pirfenidone livermetabolite). Comparing the initial rapid elimination of pirfenidone fromthe lung tissue and parallel appearance of pirfenidone in the plasmasuggest that direct pulmonary administration may be a good route forsystemic administration of pirfenidone. The delayed appearance of5-Carboxy-pirfenidone metabolite supports this hypothesis in that thismetabolite serves as a marker for re-circulation of pirfenidone to thelung and other tissues following direct aerosol administration to thelung. Further, as suggested in Tables 15 and 16 and supported by themodeled data in FIG. 1 and Table 20, re-circulated pirfenidone likelycontributes to long-term pirfenidone levels in the lung and othertissues of potential efficacy.

To understand pirfenidone human lung tissue distribution and associatedpharmacokinetics following a 10-12 minute aerosol administration from anebulizer, measured rat pharmacokinetic and lung tissue distributiondata following bolus nebulizing catheter administration was scaled.Briefly, using allometric scaling, rat aerosol lung data and plasmadelivery was scaled to humans. Rat data was taken from Table 16 and 17.Allometric scaling used parameters established in the US FDA Guidancefor Industry—Estimating the Maximum Safe Starting Dose in InitialClinical Trials for Therapeutics in Adult Healthy Volunteers. July,2005, and Caldwell et al., European Journal of Drug Metabolism andPharmacokinetics, 2004, Vol. 29, No. 2, pp. 133-143. For comparativepurposes, human plasma pharmacokinetic data resulting from oraladministration was taken directly Rubino et al., 2009. For oral data,fed-state human data was used. To model plasma pirfenidonepharmacokinetics where plasma pirfenidone was delivered from aerosoladministration, pharmacokinetics data from fasting-state humans was used(Rubino et al., 2009). Inhaled aerosol-derived plasma pirfenidone levelswere calculated based upon an assumed 100% bioavailability of inhaled,respirable-deposited pirfenidone to a 5,000 mL total blood volume. Thecontribution of plasma-derived pirfenidone (whether from oral or aerosolinhalation dosing) to lung tissue distribution and pharmacokineticsassumed at any given time 50% of plasma pirfenidone was delivered to thelung tissue. By example, a plasma level of 10 μg/mL contributed 5μg/gram pirfenidone to the lung tissue. Results of this analysis areshown in FIG. 1 and Table 20.

Aerosol deliver parameters based on Table 10 formulationcharacterization in high-efficiency, mesh-based nebulizers (Tables11-13). Respirable delivered dose (RDD) calculated by the product offine particle fraction (FPF, % ≤5 microns) and inhaled mass. An about110 mg RDD was calculated from a 5 mL device-loaded dose of a 40 mg/mLpirfenidone formulation (200 mg loaded dose). The FPF and inhaled masswere 85% and 67%, respectively. Inhaled mass was calculated based uponbreathing pattern. A 1:1 inhalation:exhalation breathing pattern (e.g. a2 second inhalation followed by a 2 second exhalation) using the eFlowdevice and 35-head is predicted to produce an inhaled mass of about 67%.From this, a 2:1 breathing pattern (e.g., a 4 second inhalation followedby a 2 second exhalation) may produce an inhaled mass between about 74%and about 80%. Using the inhaled mass of 74% and the FPF of 85%, a 200mg device-loaded dose may produce an RDD of about 125 mg. Similarly, theinhaled mass of 80% may produce an RDD of about 136 mg from a 200 mgdevice-loaded dose. Continuing, a 3:1 breathing pattern (e.g., a 6second inhalation followed by a 2 second exhalation) may produce aninhaled mass between about 80% and about 87%. Using the inhaled mass of87% and the FPF of 85%, a 200 mg device-loaded dose may produce an RDDof about 148 mg. In some embodiments, the RDD may be further increasedor decreased by additional means: by non-limiting example, changing thedevice-loaded volume and/or changing the formulation pirfenidoneconcentration. In some embodiments, increasing the formulationconcentration to 50 mg/mL and using the 5 mL device-loaded volume willprovide a 250 mg device-loaded dose. Using the FPF of 85% and inhaledmass of about 67%, a 250 mg device-loaded dose may produce an RDD ofabout 142 mg, a 74% inhaled mass may produce an RDD of about 157 mg, a80% inhaled mass may produce an RDD of about 170 mg, and a 87% inhaledmass may produce an RDD of about 185 mg. Additional dose escalations arepossible with increased co-solvent addition to the pirfenidoneformulation. Similarly, dose de-escalations are possible with reduceddevice-loaded dose (reduced volume and/or reduced pirfenidoneformulation concentration) and/or less-efficient breathing pattern.While allometric scaling is an established means to predictpharmacokinetic parameters and dose scaling between animals and humans,precedent exists that supports human-inhaled therapies remaining in thelung significantly longer than the duration predicted by allometricscaling. This possibility may also result in longer lung pirfenidoneresidence time and may also translate to reduced plasma exposure.

TABLE 20 Modeled human pirfenidone pharmacokinetics and tissuedistribution. Aerosol (RDD^(a)) Oral (801 mg) 110 mg 154 mg 185 mgFed-State Fasted-State Parameter LT P LT P LT P LT P LT P Cmax^(b) 57.517.7 71.2 24.8 85.8 30.0 3.9 7.9 7.1 14.2 AUC^(c) 43.4 68.9 61.0 96.875.1 118.3 22.1 58.9 33.9 67.7 TOE^(d) 8.7 — 9.9 — 10.4 — 10.4 — 10.0 —T_(1/2 alpha) (min) 5 — 5 — 5 — — — — — T_(1/2 beta) (hr)^(e) 2.5 2.52.5 2.5 2.5 2.5 2.4 2.4 2.5 2.5 T_(1/2 Absorption) — 0.1 — 0.1 — 0.1 —1.8 — 0.4 (hr)^(f) LT = lung tissue; P = plasma. ^(a)RDD: respirabledelivered dose = fine particle fraction (FPF; % particles <5 microns) ×inhaled mass ^(b)Cmax: Lung tissue = microgram/gram; plasma =microgram/mL ^(c)AUC: Expressed as AUC over 0-18 hours, Lung tissue inmg · hr/kg and plasma expressed in mg · hr/L. ^(d)TOE: Time of exposuremeasured as minutes over 1 microgram/gram lung tissue ^(e)T_(1/2 beta):Lung tissue pirfenidone levels and associated beta phase lung tissueT_(1/2) derived solely from plasma-pirfenidone and hence, plasmapirfenidone T_(1/2). Aerosol = Rubino et al., 2009 fasted-state; Oral =Rubino et al., 2009 ^(f)T_(1/2 absorption): Aerosol = modeled fromallometrically-scaled bolus aerosol rat data; Oral = Rubino et al.,2009.

Example 8: Pharmacokinetics and Lung-Tissue Distribution

Previous intratracheal aerosol delivery (see Example 6) was performed asa single bolus instillation just above the first bifurcation of thelung. For in vivo efficacy studies, an attempt was made to mimic tidalinhaled breathing by splitting the dose into equal parts andadministering as before, but over a 2 minute period. For this work,Wistar rats (300-500 grams) in groups of four were either administeredpirfenidone by bolus aerosol (intratracheal Penn Century MicroSprayer®nebulizing catheter) split into 6 equal administrations of 50 mcL/animal(approximately 20 seconds apart) for a total of 300 mcL/animal over atotal of 2 minutes, or by bolus oral gavage (300 mcL/animal). Doses wereprepared in 0.45% sodium chloride solution and were administered asdescribed in Table 21.

TABLE 21 Extended-duration intratracheal and oral pharmacokinetic studydose groups Dose Dose Level of Formulation No. of Group GroupPirfenidone Concentration Male Numbers Designation (mg/kg) (mg/mL)Animals 1 IT - Low Dose 2.5 3.75 32 2 IT - Mid Dose 5 7.5 32 3 IT - HighDose 10 15 32 4 Oral - Low Dose 10 1 32 5 Oral - Mid Dose 30 3 32 6Oral - High Dose 100 10 32 7 Control N/A N/A 4

Plasma samples and entire lungs were taken at pre-dose, 2, 4, 6, 10, 30,60 and 120 minutes post dosing. Materials were extracted and pirfenidonequantitated as mcg/mL plasma and μg/gram lung tissue. Results from thesestudies are shown in Table 22. No adverse events were noted in thesestudies.

TABLE 22 Extended-duration intratracheal and oral pharmacokineticresults IntratrachealAerosol Oral Gavage (mg/kg) (mg/kg) 2.5 5 10 10 30100 Lung Tissue Cmax 14.4 27.9 61.1 3.5 9.8 33.6 AUC_((0-2 hr)) 3.5 6.614.5 4.9 13.5 27.9 Plasma Cmax 3.4 8.8 22.8 3.6 9.8 26.3 AUC_((0-2 hr))3.2 5.8 14.6 4.4 12.9 24.2

Example 9. In Vivo Efficacy—Bleomycin Model of Pulmonary Fibrosis

To compare anti-fibrotic efficacy between extended-durationintratracheal, direct-lung aerosol administration and oral gavage, thebleomycin model of pulmonary fibrosis was performed. Doses for thisstudy were selected based upon pharmacokinetic parameters obtained inTable 22 (from Example 8). Briefly, Wistar rats (175-225 grams) wereadministered bleomycin by the intratracheal route using a Penn CenturyMicroSprayer® catheter. On the seventh day following bleomycin exposure,animals initiated treatment with either saline or pirfenidone. Animalswere dosed once a day on days 7 through 28, and euthanized on day 29.Pirfenidone was administered either intratracheally using Penn CenturyMicroSprayer catheter or by oral gavage. Sham and bleomycin controlgroups received either no treatment or intratracheal saline by PennCentury MicroSprayer catheter. While dosing more frequently (or lessfrequently) may improve the observed effects, anesthesia required forintratracheal administration reduced animal weight gain (reduced foodintake) and, thus limited dosing to once a day for this study. Becauseanesthesia reduced weight gain, all study animals (intratracheal, oraland control) received once-a-day isoflurane using the same technique andduration. Twelve animals were enrolled into each dosing group. For oralpirfenidone, one group received 30 mg/kg by oral gavage, while thesecond group received 100 mg/kg. For intratracheal pirfenidoneadministration, one group received 0.9 mg/kg (targeted to match 30 mg/kgoral lung tissue Cmax), a second group received 3.0 mg/kg (targeted tomatch 100 mg/kg oral lung tissue Cmax), and a third group received 6.4mg/kg (targeted to match 30 mg/kg oral plasma AUC). Oral gavage wasadministered in a single 300 mcL volume. Due to technical restrictions,instead of the mg/kg dose being equally split between six 50 mcLadministrations over 2 minutes, intratracheal administration wasperformed with three equal 50 mcL volumes administered every 40 secondsover the same period. For dose selection, data from Table 22 wasextrapolated. On day 29, animals were euthanized. Right lungs wereextracted and measured for hydroxyproline content, while left lungs weresubjected to histology. Histological sections were stained withpicrosirius red and scored for lung tissue fibrosis. Twenty randomphotographs of each stained lung tissue section were taken, blinded andscored by an independent review panel. Observations were pooled foranalysis. Data and results from these studies are shown in Tables 23,24, 25, 26 and 27, and FIGS. 3 and 4.

TABLE 23 Bleomycin study doses and resultant pharmacokinetic parametersLung Tissue Plasma Pirfenidone Cmax AUC_(0-2 hrs) Cmax AUC_(0-2 hrs)Group^(a) (mg/kg) (mcg/g) (mcg*hr/g) (mcg/mL) (mcg*hr/mL) Bleomycin + 3011.8 18.2 10.3 16.6 PO Pirfenidone Bleomycin + 100 33.6 34.4 21.7 29.6PO Pirfenidone Bleomycin + 0.9 11.6 2.6 2.6 3.0 IT PirfenidoneBleomycin + 3.0 33.5 7.3 10.9 7.7 IT Pirfenidone Bleomycin + 6.4 71.515.5 23.3 16.5 IT Pirfenidone ^(a)IT: intratracheal; PO: oral gavage.

TABLE 24 Right lung hydroxyproline content Average STDV PirfenidoneHydroxyproline Hydroxyproline Group^(a) (mg/kg) (mg/right lung)(mg/right lung) Sham 0 1.87 0.11 Sham + IT saline 0 1.90 0.13 Bleomycin0 3.22 0.15 Bleomycin + 0 3.58* 0.35 IT saline Bleomycin + 30 3.65 0.67PO Pirfenidone Bleomycin + 100 3.73 0.79 PO Pirfenidone Bleomycin + 0.92.88* 0.68 IT Pirfenidone Bleomycin + 3.0 3.56 0.49 IT PirfenidoneBleomycin + 6.4 3.50 0.32 IT Pirfenidone ^(a)IT: intratracheal; PO: oralgavage. *P-value = 0.041.

TABLE 25 Right lung Hydroxyproline content - Intratracheal aerosolversus oral Gavage Difference from bleomycin control^(b) Average STDVPirfenidone Hydroxyproline Hydroxyproline Group^(a) mg/kg (mg/rightlung) (mg/right lung) Bleomycin + 30 0.43*,**  0.67 PO PirfenidoneBleomycin + 100 0.51***   0.79 PO Pirfenidone Bleomycin + 0.9−0.70*,****  0.68 IT Pirfenidone Bleomycin + 3.0 −0.02**,**** 0.49 ITPirfenidone Bleomycin + 6.4  −0.08***,**** 0.32 IT Pirfenidone ^(a)IT:intratracheal, PO: oral gavage; ^(b)mg/right lung hydroxyproline shamvalues were subtracted from treated values. Sham-subtracted treatedvalues were then subtracted from bleomycin control values. *P-value =0.012, **P-value = 0.084, ***P-value = 0.075, ****P-value = 0.049 and0.053 for IT 0.9 mg/kg to IT 3.0 mg/kg and IT 6.4 mg/kg, respectively.

TABLE 26 Fibrosis Score - Picrosirius Red-Stained Left Lung SectionsAverage Pirfenidone Fibrosis STDV Group^(a) (mg/kg) Score FibrosisScoreSham 0 0.46 0.14 Sham + IT saline 0 0.36 0.16 Bleomycin 0 2.43 0.60Bleomycin + IT saline 0  3.40 * 0.69 Bleomycin + PO Pirfenidone 30 3.110.65 Bleomycin + PO Pirfenidone 100 3.61 0.85 Bleomycin + IT Pirfenidone0.9  2.88 * 1.00 Bleomycin + IT Pirfenidone 3.0 3.66 1.19 Bleomycin + ITPirfenidone 6.4 3.47 1.46 ^(a)IT: intratracheal; PO: oral gavage. *P-value = 0.144.

TABLE 27 Fibrosis Score - Intratracheal aerosol versus oral GavageDifference from bleomycin control^(b) Average STDV Pirfenidone FibrosisFibrosis Group^(a) mg/kg Score Score Bleomycin + 30 0.68 *, **   0.65 POPirfenidone Bleomycin + 100 1.18 ***   0.85 PO Pirfenidone Bleomycin +0.9 −0.53 *, ****  1.00 IT Pirfenidone Bleomycin + 3.0  0.26 ***, ****1.19 IT Pirfenidone Bleomycin + 6.4 0.07 **, **** 1.46 IT Pirfenidone^(a)IT: intratracheal, PO: oral gavage; ^(b)fibrosis score sham valueswere subtracted from treated values. Sham-subtracted treated values werethen subtracted from bleomycin control values. * P-value = 0.007, **P-value = 0.214, *** P-value = 0.042, **** P-value = 0.121 and 0.214 forIT 0.9 mg/kg to IT 3.0 mg/kg and IT 6.4 mg/kg, respectively.

Doses selected for this study targeted critical pharmacokineticparameters from the comparator oral route (matching lung tissue Cmax orplasma AUC). These targets were selected from a pharmacokinetic studywherein lung tissue and plasma were collected and pirfenidone levelswere compared. In these studies, lung tissue Cmax followingintratracheal administration was always the first collected time point.It is important to consider that the duration of time required tocollect this first lung tissue may not accurately capture the true lungCmax. In our studies, collection time was about 1 minute. It was thispharmacokinetic point that the above Cmax for dosing was selected. If itwas possible to collect lung tissue earlier, the Cmax may be higher. Asthe Penn Century MicroSprayer catheter delivers nearly the entire loadeddose, the possible delivered Cmax in these studies may be higher. Byexample, a 250 gram rat lung weighs about 1.5 grams. Delivering a 0.9mg/kg dose (225 mg) to this animal would result in up to a 150 mcg/gramlung tissue Cmax. In this study, we divided the dose into thirds.Therefore, the possible Cmax was about 50 mcg/gram lung tissue (about 5×that actually delivered by the 30 mg/kg oral dose). To theinterpretation that large systemic pirfenidone exposure reduces lungefficacy, a nearly 150 to 200 mg/kg oral dose would be required toachieve a 50 mcg/gram lung tissue Cmax, a dose that the oral safetyprofile will not permit.

From these results, and other nonclinical and clinical experience withthe pirfenidone, it appears lung Cmax is important for anti-fibroticefficacy. Further, while Cmax is important, high systemic exposurereduces this effect. While oral dosing delivers a very large plasma AUC,only a small lung tissue Cmax is obtained. Comparatively, to achieve alow lung tissue dose, relatively small aerosol doses can be delivereddirectly to the lung to achieve high lung tissue Cmax levels with lowersystemic exposure; an administration profile not possible with oraldelivery.

Results from this study show that pirfenidone delivered directly to thelung is more efficacious (less fibrosis and less hydroxyproline).However, large systemic pirfenidone exposure either directly orindirectly reduces this effect. More specifically, the oral routerequires a large oral dose to achieve a relatively small lung tissueCmax. Delivering a similar Cmax without the large systemic dose providesincreased efficacy. However, further escalating this direct lung dose,which results in increased systemic exposure, reduces this effect.Coupling these results with other published observations (Swaney et al.Br. J. Pharmacol. 160(7):1699-713, 2010; Tian et al., Chin. Med. Sci. J.21(3):145-51, 2006; and Trivedi et al., Nanotechnology. 23(50):505101,2012), it is evident that pirfenidone follows an AUC-dependent, U-shapeddose response. Specifically, a high lung tissue Cmax is important forlung tissue anti-fibrotic efficacy. However, this positive effectappears dependent upon an associated small plasma AUC; the larger theplasma AUC, the lower the efficacy. FIGS. 3 and 4 show theAUC-dependent, U-shaped pirfenidone dose response. In practice, the oralroute of administration is not capable of meeting thisU-shaped-restricted dose response. Safety and tolerability preventfurther dose escalation of the 801 mg/dose oral medicine (Esbriet®).These data and other published studies (Swaney et al., 2010, Tian etal., 2006, and Trivedi et al., 2012) indicate that if oral escalationwere possible, the associated increase in plasma AUC may reduce ornegate any associated lung tissue Cmax advantage. Comparatively,inhalation of small aerosol pirfenidone doses enable dosing within theconfines of the U-shaped dose response; high lung tissue Cmax, lowplasma AUC. To illustrate these findings, possible human lung tissue andplasma pharmacokinetics following tidal-breath-inhaled aerosoladministration were again modeled (FIG. 5). As mentioned, safety andtolerability restrict further escalation of the 801 mg oral pirfenidonedose (801 mg taken three times a day). These safety and/or tolerabilityrestrictions may be associated with plasma AUC, plasma Cmax,gastrointestinal exposure or a combination of these events. For purposesof the model, the plasma AUC resulting from an 801 mg oral pirfenidonedose was established as the limit for inhaled aerosol pirfenidoneadministration. However, this limitation could also be set as the plasmaCmax or a combination of these pharmacokinetic parameters.

Aerosol deliver parameters for the FIGS. 2 and 5 models were based onhigh-efficiency, mesh-based nebulizer characterization (Table 12). Thelung half-life following aerosol delivery was scaled from both bolusintratracheal (Examples 6 and 7) and extended-duration, intratrachealpirfenidone pharmacokinetic results (Example 8). Respirable delivereddose (RDD) calculated by the product of fine particle fraction (FPF, %≤5 microns) and inhaled mass. Using a pulmonary half-life obtained frombolus intratracheal pharmacokinetic results, the modeled humanpharmacokinetics following about 5 minute tidal inhalation of a 47 mgRDD was calculated from a 3.6 mL device-loaded dose of 25 mg/mLpirfenidone formulation (90 mg loaded dose). For this non-limitingexample, a FPF of 78% and inhaled mass of 67% was used. Using thesenumbers, a 90 mg device-loaded dose may produce an RDD of about 47 mg(Table 26 and FIG. 2). Using a pulmonary half-life obtained fromextended-duration, intratracheal pharmacokinetic results the modeledhuman pharmacokinetics following tidal inhalation of 120 mg, 50 mg and2.5 mg RDDs were again calculated (FIG. 5). An about 120 mg RDD wascalculated from a 3.6 mL device-loaded dose of a 68 mg/mL pirfenidoneformulation (230 mg loaded dose). For this non-limiting example, a FPFof 78% and inhaled mass of 67% was used. Using these numbers, a 230 mgdevice-loaded dose may produce an RDD of about 120 mg. The about 50 mgRDD was calculated from a 3.6 mL device-loaded dose of a 27 mg/mLpirfenidone formulation (96 mg loaded dose). Similarly, the 2.5 mg RDDwas calculated from a 0.66 mL device-loaded dose of a 7.2 mg/mLpirfenidone formulation (4.8 mg loaded dose). This later dose wasmodeled to be delivered in 1 minute. Additional dose escalations arepossible with increased co-solvent addition to the pirfenidoneformulation. Similarly, dose de-escalations are possible with reduceddevice-loaded dose (reduced volume and/or reduced pirfenidoneformulation concentration) and/or less-efficient breathing pattern.Reductions in pirfenidone formulation concentration below about 20 mg/mLmay not require co-solvents, but may include buffer, permeant ion,osmolality-adjusting agent or taste-masking agent. Pulmonary eliminationand plasma exposure assume 100% bioavailability following inhaledaerosol administration. Thus, it is possible that actual human plasmapirfenidone exposure may be less following human inhaled administration.

TABLE 28 Modeled human pirfenidone pharmacokinetics and tissuedistribution. Tidal-Inhaled Aerosol (47 mg RDD^(a)) Alpha T_(1/2) = Oral(801 mg)* 3.5 min Fed-State Fasted-State Lung Lung Lung Parameter TissuePlasma Tissue Plasma Tissue Plasma Cmax^(b) 52.2 7.8  3.9 7.9  7.1 14.2AUC (0-18 42.3 37.2  22.1 58.9  33.9 67.7 hrs)^(c) TOE (hrs > 1 9.4 —10.4 — 10.0 — μg/g)^(d) T_(1/2 alpha) (min) 3.5 — — — — — T_(1/2 beta)(hr)^(e) 2.5 2.5  2.4 2.4  2.5 2.5 T_(1/2) Absorption — 0.4 — 1.8 — 0.4(hr)^(f) ^(a)RDD: respirable delivered dose = fine particle fraction(FPF; % particles <5 microns) × inhaled mass. ^(b)Cmax: Lung tissue =microgram/gram; plasma = microgram/mL. ^(c)AUC: Expressed as AUC over0-18 hours, Lung tissue in mg · hr/kg and plasma expressed in mg · hr/L.^(d)TOE: Time of exposure measured as minutes over 1 microgram/gram lungtissue. ^(e)T_(1/2 beta): Lung tissue pirfenidone levels and associatedbeta phase lung tissue T_(1/2) derived solely from plasma-pirfenidoneand hence, plasma pirfenidone T_(1/2). Aerosol = Rubino et al., 2009fasted-state; Oral = Rubino et al., 2009. ^(f)T_(1/2 absorption):Aerosol = modeled from allometrically-scaled bolus aerosol rat data;Oral = Rubino et al., 2009.

An additional clinical consideration is the rat plasma AUC showingnon-efficacy in the bleomycin model. By non-limiting example, as shownin FIGS. 3 and 4, a 3.0 mg/kg intratracheal, direct lung aerosol ratdose results in a plasma AUC that has no observed pirfenidone efficacy.Only lower delivered doses show anti-fibrotic effect. Plasma AUCsobtained from higher intratracheal or oral doses appears to have similarnon-efficacy or enhanced disease. Therefore, it could be argued thatinhalation-delivered plasma AUCs less than that obtained from a 3 mg/kgintratracheal dose may be important to permit pirfenidone efficacy.Using allometric scaling (by total body surface area), a 3 mg/kg ratdose scaled to a 60 kg human results in a 29 mg human lung-delivereddose (assuming equal pulmonary elimination rate and 100%bioavailability). From this, a consideration in human doses may be thatan RDD equivalent to a 29 mg intratracheal aerosol dose may result in ahuman plasma AUC representing the upper threshold of the U-shapedpirfenidone dose response curve. Using the extended-durationintratracheal pharmacokinetic data model, the possible achieved humanlung tissue Cmax and plasma AUC_(0-18hrs) following a 3 minutetidal-inhaled nebulized dose resulting in a 29 mg RDD is 43.2 mcg/gramlung tissue and 13.4 mcg·hr/mL, respectively.

Example 10. Pirfenidone Formulations for Low Concentration Dosage Forms

TABLE 29 Pirfenidone formulations for low concentration dosage formsPhosphate Formulations Citrate Buffer Formulations Water Formulations 5mM sodium phosphate, pH 7 (+/−0.5) 5 mM citrate buffer, pH 5.5 (+/−0.5)Water 50 mM NaCl 50 mM NaCl 50 mM NaCl 16 mg/mL pirfenidone 16 mg/mLpirfenidone 16 mg/mL pirfenidone 5 mM sodium phosphate, pH 7 (+/−0.5) 5mM citrate buffer, pH 5.5 (+/−0.5) Water 100 mM NaCl 100 mM NaCl 100 mMNaCl 4 mg/mL pirfenidone 4 mg/mL pirfenidone 4 mg/mL pirfenidone 5 mMsodium phosphate, pH 7 (+/−0.5) 5 mM citrate buffer, pH 5.5 (+/−0.5)Water 43.3 mM MgCl2 43.3 mM MgCl2 43.3 mM MgCl2 16 mg/mL pirfenidone 16mg/mL pirfenidone 16 mg/mL pirfenidone 5 mM sodium phosphate, pH 7(+/−0.5) 5 mM citrate buffer, pH 5.5 (+/−0.5) Water 43.3 mM MgCl2 43.3mM MgCl2 43.3 mM MgCl2 50 mM NaCl 50 mM NaCl 50 mM NaCl 16 mg/mLpirfenidone 16 mg/mL pirfenidone 16 mg/mL pirfenidone 5 mM sodiumphosphate, pH 7 (+/−0.5) 5 mM citrate buffer, pH 5.5 (+/−0.5) Water 10.8mM MgCl2 10.8 mM MgCl2 10.8 mM MgCl2 4 mg/mL pirfenidone 4 mg/mLpirfenidone 4 mg/mL pirfenidone 5 mM sodium phosphate, pH 7 (+/−0.5) 5mM citrate buffer, pH 5.5 (+/−0.5) Water 10.8 mM MgCl2 10.8 mM MgCl210.8 mM MgCl2 100 mM NaCl 100 mM NaCl 100 mM NaCl 4 mg/mL pirfenidone 4mg/mL pirfenidone 4 mg/mL pirfenidone 5 mM sodium phosphate, pH 7(+/−0.5) 2% Ethanol Water 2% Ethanol 4% Propylene Glycol 2% Ethanol 4%Propylene Glycol 22 mg/mL pirfenidone 4% Propylene Glycol 22 mg/mLpirfenidone 22 mg/mL pirfenidone 5 mM sodium phosphate, pH 7 (+/−0.5) 5mM citrate buffer, pH 5.5 (+/−0.5) Water 50 mM NaCl 50 mM NaCl 50 mMNaCl 0.1-1.0 mM sodium 0.1-1.0 mM sodium 0.1-1.0 mM sodium saccharinsaccharin saccharin 16 mg/mL pirfenidone 16 mg/mL pirfenidone 16 mg/mLpirfenidone 5 mM sodium phosphate, pH 7 (+/−0.5) 5 mM citrate buffer, pH5.5 (+/−0.5) Water 100 mM NaCl 100 mM NaCl 100 mM NaCl 0.1-1.0 mM sodium0.1-1.0 mM sodium 0.1-1.0 mM sodium saccharin saccharin saccharin 4mg/mL pirfenidone 4 mg/mL pirfenidone 4 mg/mL pirfenidone 5 mM sodiumphosphate, pH 7 (+/−0.5) 5 mM citrate buffer, pH 5.5 (+/−0.5) Water0.1-1.0 mM sodium 0.1-1.0 mM sodium 0.1-1.0 mM sodium saccharinsaccharin saccharin 43.3 mM MgCl2 43.3 mM MgCl2 43.3 mM MgCl2 16 mg/mLpirfenidone 16 mg/mL pirfenidone 16 mg/mL pirfenidone 5 mM sodiumphosphate, pH 7 (+/−0.5) 5 mM citrate buffer, pH 5.5 (+/−0.5) Water0.1-1.0 mM sodium 0.1-1.0 mM sodium 0.1-1.0 mM sodium saccharinsaccharin saccharin 43.3 mM MgCl2 43.3 mM MgCl2 43.3 mM MgCl2 50 mM NaCl50 mM NaCl 50 mM NaCl 16 mg/mL pirfenidone 16 mg/mL pirfenidone 16 mg/mLpirfenidone 0.1-1.0 mM sodium 0.1-1.0 mM sodium 0.1-1.0 mM sodiumsaccharin saccharin saccharin 5 mM sodium phosphate, pH 7 (+/−0.5) 5 mMcitrate buffer, pH 5.5 (+/−0.5) Water 10.8 mM MgCl2 10.8 mM MgCl2 10.8mM MgCl2 4 mg/mL pirfenidone 4 mg/mL pirfenidone 4 mg/mL pirfenidone0.1-1.0 mM sodium 0.1-1.0 mM sodium 0.1-1.0 mM sodium saccharinsaccharin saccharin 5 mM sodium phosphate, pH 7 (+/−0.5) 5 mM citratebuffer, pH 5.5 (+/−0.5) Water 10.8 mM MgCl2 10.8 mM MgCl2 10.8 mM MgCl20.1-1.0 mM sodium 0.1-1.0 mM sodium 0.1-1.0 mM sodium saccharinsaccharin saccharin 100 mM NaCl 100 mM NaCl 100 mM NaCl 4 mg/mLpirfenidone 4 mg/mL pirfenidone 4 mg/mL pirfenidone 5 mM sodiumphosphate, pH 7 (+/−0.5) 5 mM citrate buffer, pH 5.5 (+/−0.5) Water0.1-1.0 mM sodium 0.1-1.0 mM sodium 0.1-1.0 mM sodium saccharinsaccharin saccharin 2% Ethanol 2% Ethanol 2% Ethanol 4% Propylene Glycol4% Propylene Glycol 4% Propylene Glycol 22 mg/mL pirfenidone 22 mg/mLpirfenidone 22 mg/mL pirfenidone

TABLE 30 Compositions and Additional Aerosol Tolerability AnalysisCitrate Phosphate Sodium Magnesium Sodium Est. Mean Aerosol BufferBuffer Chloride Chloride Saccharin Pirfenidone Osmolality Particl SizeMetallic Throat General (mM) (mM) (mM) (mM) (mM) pH (+/−0.5) (mg/mL)(mOsmo/Kg) (micron)^(a) Taste^(b) Irritation^(b) Taste^(b) 0 5 50 0 0 716 200 3.7 5 5 3 0 5 0 43.3 0 7 16 210 3.7 5 5 3 0 5 0 43.3 0.5 7 16 2103.7 5 5 1 0 5 50 43.3 0 7 16 310 3.7 5 4 2 0 5 150 0 0 7 16 400 3.7 5 32 5 0 150 0 0 5.5 16 400 3.7 4 4 2 5 0 0 130 0 5.5 16 490 3.7 5 3 2 5 0100 43.3 0 5.5 16 430 3.7 4 3 2 5 0 100 43.3 0.6 5.5 16 430 3.7 4 2 1 50 150 0 0.5 5.5 16 400 3.7 2 1 2 5 0 150 0 0.9 5.5 16 400 3.7 1 1 1 5 00 130 0.5 5.5 16 490 3.7 1 2 2 5 0 100 0 0 5.5 16 400 3.7 3 3 2 5 0 1000 0.7 5.5 16 400 3.2 2 3 2 5 0 100 0 0.7 5.5 16 400 4.6 1 1 2 5 0 100 00 5.5 16 400 3.2 1 2 2 5 0 100 0 0 5.5 16 400 3.7 2 3 2 5 0 100 0 0.75.5 16 400 3.7 3 2 2 5 0 100 0 0.9 5.5 16 400 3.7 2 2 1 5 0 100 0 0.95.5 16 400 3.2 2 1 1 0 0 150 0 0 ND 16 375 3.2 3 5 3 0 0 150 0 0.7 ND 16375 3.2 2 5 2 5 0 150 0 0 5.5 4 330 3.2 2 1 2 5 0 150 0 0 5.5 4 330 3.72 2 2 5 0 150 0 0.2 5.5 4 330 3.7 2 2 2 5 0 150 0 0.3 5.5 4 330 3.7 1 11 5 0 100 0 0 5.5 4 270 3.2 2 2 2 5 0 100 0 0.3 5.5 4 270 3.7 1 2 1^(a)Estimate based upon general device performace with pirfenidoneformulations. 3.7 and 3.2 micron particles sizes were delivered by highoutput device (~0.7 mL/minute). 4.6 micron particle sizes were deliveredby a slower output device (~0.5 mL/minute). ^(b)Throat irritation: 1 =none, 5 = strong; b. General taste: 1 = good, 3 = bad

Table 30 results indicate that slower device outputs (less than or about0.5 mL/minute) improve tolerability (even with a larger particle size)over smaller particles of greater output (more than or about 0.7mL/min). This output aerosol tolerability difference can be overcomewith inclusion of the following liquid formulation characteristics: 1.that the pH range between 5 and 6 is generally better than the neutralpH; 2. sodium chloride is more well tolerated than magnesium chloride,which tends to carry a stronger metallic flavor; 3. citrate buffer (andassociated pH range) is more well tolerated than phosphate buffer; andinclusion of between 0.5 and 0.9 mM sodium saccharin for pirfenidoneconcentrations about 16 mg/mL and between 0.1 and 0.4 mM sodiumsaccharin for pirfenidone concentrations about 4 mg/mL (to be titratedfor optimal taste and tolerability between these two and variouspirfenidone concentrations. In addition to sodium saccharin, 5 mM sodiumcitrate buffer, pH about 5.5 and about 150 mM sodium chloride areoptimal for pirfenidone concentrations below and up to aqueoussaturation solubility. Additional observations include maintainingosmolality between about 250 to about 500 mOsmo/kg. The tolerability forformulations with an osmolality outside this range may be adjusted withmodifications in the above formulation parameters and device output andaerosol particle size characteristics.

Example 11: Nebulization Device Performance

To evaluate aerosol performance, several formulations (Table 31) weretested in the PARI eFlow device. For these studies the standard eFlow35L head was used. Particle size distribution was determined using anInsitec Spraytec Laser Particle Sizer. Breath simulation was performedusing a Servo 1000i ventilator attached to a respiratory therapytraining lung. The European Standard breath pattern (15 breaths perminute, 500 cc tidal volume and 1:1 inhalation-to-exhalation ratio) wasused in determinations. Results from these studies are shown in Table 32and 33. Each result is an average of duplicate trials in each of threedevices.

TABLE 31 Device characterization formulations Ingredient Formulation 1Formulation 2 Pirfenidone (mg/mL) 15.0 4.0 Sodium citrate, dihydrate(mM) 3.5 3.5 Citric acid, monohydrate (mM) 1.5 1.5 Sodium Chloride (mM)150.0 150.0 Sodium Saccharin (mM) 0.9 0.9 Water (q.s.) q.s. q.s.

TABLE 32 Nebulized aerosol particle sizing Formulation (Table 31): 1 2Fill volume: mL  3.0 3.0 Label claim mg/mL 15.0 4.0 Dv(90)^(a) (stdv) μm6.04 (0.46) 6.25 (0.34) Dv(50)^(a) (stdv) 3.72 (0.13) 3.77 (0.18) DV(10)^(a) (stdv) 2.21 (0.26) 1.84 (0.56) Span^(b) (stdv) 1.03 (0.19) 1.17(0.18) RF^(c) (stdv) % <5 μm 77.93 (4.13)  75.68 (3.07)  ^(a)Dv(X):Maximum particle diameter below which 90%, 50% (median populationparticle size) and 10% of the sample volume exists.; ^(b)Span = [Dv(90)− Dv(10)]/Dv(50); ^(c)Respirable fraction (RF) is the percent ofnebulized particles <5 μm.

TABLE 33 Nebulized aerosol breath simulation Formulation from Table 31:1 2 Fill Volume mL 2.0 2.0 Lable Claim mg/mL 15.0 4.0 Inhaled Dose mg19.9 5.5 Inhaled Dose % 66.3 68.8 Residual Dose mg 4.5 1.1 Recovery %81.4 82.2 Nebulization Time min 2.9 3.1 TOR^(a) mg/min 6.9 1.8 RDD^(b)mg 15.5 4.2 ^(a)Total output rate (TOR); ^(b)Respirable delivered dose(RDD) calculated by multiplying the inhaled dose (mg) and respirablefraction (Table 32).

These results show that 2 mL of a 15 mg/mL pirfenidone formulation willbe administered in 2.9 minutes and result in a 15.5 mg RDD. Theseresults also show that 2 mL of a 4 mg/mL pirfenidone formulation will beadministered in 3.1 minutes and result in a 4.2 mg RDD. Manipulation ofthe pirfenidone concentration and device fill volume will permitoptimization of dose delivery time and lung Cmax/plasma exposure ratio.

Example 12. Pirfenidone Activity and Exposure Requirements—InflammasomeActivation and Fibroblast Differentiation Inflammasome Activation

The impact of pirfenidone on inhibiting the initial stage ofinflammasome activation was determined in 264.7 macrophages. Briefly,macrophage were plated on a 96 well plate with seeding density of 100000 cells per well. Cells were then incubated overnight. The next daycells received 200 ng/ml of LPS and various pirfenidone concentrationsand incubated for 4 hours in 0% FBS media. To characterize the impact ofpirfenidone time of exposure on inhibiting this step, these cultureswere either diluted or left untouched. To mimic inhaledpharmacokinetics, cultures were diluted 2-fold at 10, 20, 30, 40, and120 minutes after LPS/pirfenidone addition. After 240 minutes ofincubation supernatants were collected. Diluted cultures did not replaceLPS. Separate controls were included for diluted cultures containing LPSor media alone. At the end of the 4 hour incubation, supernatants wereremoved and 2 mM ATP was added. Cultures were incubated an additional 40minutes. Supernatants were collected for quantitation of secreted IL-1β.0% FBS media containing MTS dye was then added to remaining cells forcytotoxicity determination.

The impact of pirfenidone on inhibiting the second stage of inflammasomeactivation was also determined in 264.7 macrophages. Briefly, macrophagewere plated on a 96 well plate with seeding density of 100 000 cells perwell. Cells were then incubated overnight. The next day cells received200 ng/ml of LPS and incubated for 4 hours in 0% FBS media. At the endof the 4 hour incubation, supernatants were removed and two approachesfor pirfenidone impact were assessed. First, media containing 0% FBSwith or without pirfenidone was added and incubated for 5 minutes. Atthe end of 5 minutes, supernatants were either removed and mediacontaining 0% FBS and 2 mM ATP were added or a final concentration of 2mM ATP was added to the pirfenidone-containing culture. Cultures wereincubated for an additional 40 minutes. Supernatants were collected forquantitation of secreted IL-1β. 0% FBS media containing MTS dye was thenadded to remaining cells for cytotoxicity determination. In the secondapproach, once LPS-containing supernatants were removed, mediacontaining 0% FBS and 2 mM ATP with or without pirfenidone were added.Where cultures were assessed for short-term pirfenidone exposure, mediawas removed after 10 minutes incubation and replaced with fresh mediacontaining 0% FBS. These cultures were incubated an additional 30minutes. Both the 10 minute and 40 minute culture supernatants wereanalyzed for secreted IL-1β. Short-term exposure results are reportedfor the 10 min sample, 40 min sample and the sum of these results. Forlonger-term pirfenidone exposure control, cultures maintainedpirfenidone throughout the 40 minute ATP incubation period. Thesesupernatants were similarly analyzed for secreted IL-1β. Under bothapproaches, 0% FBS media containing MTS dye was then added to remainingcells for cytotoxicity determination.

TABLE 34 Impact of pirfenidone and exposure duration on inflammsomefirst signal activation. Pirfenidone Exposure Pirfenidone Short-termLonger-term LPS ATP mcg/mL IL-1β^(a) SEM IL-1β^(a) SEM + + 0 1.00 0.041.00 0.08 + + 25 0.50 0.05 0.55 0.07 + + 100 0.08 0.03 0.39 0.02 + + 4000.04 0.03 0.07 0.01 + + 1600 0.12 0.02 0.03 0.00 ^(a)Relative

Results from Table 34 show that pirfenidone is dose-responsive ininhibiting first-signal inflammasome activation. The data also show thatonly short-term pirfenidone exposure is required for this activity witha fifty-percent inhibitory concentration (IC50) of about 25 mcg/mL.

TABLE 35 Impact of pirfenidone and exposure duration on inflammsomesecond signal activation. Pirfenidone Exposure Short-term 10 + 40 10min > 40 min > min > Longer-term Pirfenidone ATP ATP ATP 40 min > ATPLPS ATP mcg/mL IL-1β^(a) SEM IL-1β^(a) SEM IL-1β^(a) SEM IL-1β^(a) SEM +− 0 10.9 2.5 19.7 1.4 0.2 0.02 0.0 0.01 + + 0 58.8 5.5 94.0 5.2 1.0 0.071.0 0.07 + + 5 81.5 5.7 95.8 11.8 1.1 0.09 1.4 0.15 + + 25 100.0 17.150.4 10.3 1.0 0.13 1.1 0.08 + + 125 118.7 5.2 36.3 3.6 1.0 0.04 0.90.06 + + 625 66.3 6.2 27.3 2.5 0.6 0.05 0.4 0.04 ^(a)pg/mL; ^(b)Relative

Results from Table 35 show that pirfenidone is also dose-responsive ininhibiting second-signal inflammasome activation. Analysis of the 10 and40 minute sampling points, suggest the kinetics of caspase 1 activation,pro-IL-1β cleavage and/or IL-1β secretion should be considered in theinterpretation. The initial 10 minute sampling point suggestspirfenidone may enhance second-signal activation. However, analysis ofthe 40 minute sampling point shows a return of dose-responsiveinhibitory activity. Comparing the sum of the short-term sampling pointsand the longer-term sampling point, inhibition of second-signalinflammasome activation appears similar between the two exposureperiods, albeit weakly dose responsive (IC50 about 625 mcg/mL). However,the IC50 reduces to about 25 mcg/mL when measuring the second samplingpoint alone. These results suggest pirfenidone activity requires ashort-period following initial exposure to achieve optimal inhibitoryactivity. Further supporting the observation that only short-termpirfenidone exposure is required for this activity.

It has been shown that the unfolded-protein response (UPR) toendoplasmic reticulum stress (ER stress) modulates both first-signal andsecond-signal inflammasome activation. Central to these data, IRE1αmodulates NFκB activation (first-signal event) and NLRP3 activation ofthe inflammasome (second signal event). Macroscopically, IRE1α inducescytokine production (via NFκB activation), which in turn modulates thepro-fibrotic IL-1β/TGFβ amplification loop (autocrine and paracrine).IRE1α also activates XBP1 (via splicing), which in turn increasesprotein chaperone production and ER secretory capacity; inhibiting IRE1αblocks the cells ability to transform from a non-secreting cell to asecreting cell. Comparing the Table 34 and Table 35 results, these datasuggest that pirfenidone may inhibit this central modulator of theUPR/inflammasome, thereby directly reducing these otherwise pro-fibroticcellular responses.

Fibroblast Differentiation

The impact of pirfenidone on inhibiting TGFβ1-induced fibroblastdifferentiation was determined in normal human pulmonary fibroblasts.Briefly, 20 000 cells per well were seeded in black 96 well collagencoated plates and incubate overnight (approximately 24 hours) to allowadherence. Following incubation, media was removed and replaced withmedia containing 0% FBS and either TGFβ1 alone or TGFβ1 with variouspirfenidone concentrations. Cultures were then incubated for 48 hours.To characterize the impact of pirfenidone time of exposure on inhibitingdifferentiation, cultures were either diluted or left untouched. Tomimic inhaled pharmacokinetics (short-term exposure), cultures werediluted 2-fold at 10, 20, 30, 40, 120, 240 and 360 minutes afterTGFβ1/pirfenidone addition. Diluted cultures did not replace TGF 1(long-term exposure). Separate controls were included for dilutedcultures containing TGFβ1 or media alone. At the end of incubation,cells were fixed and stained for imaging and fluorescence plate readerquantitation. Parallel cultures were assessed for cytotoxicity using theMTS dye assay.

TABLE 36 Impact of pirfenidone and exposure duration on TGFβ-inducedfibroblast differentiation. Pirfenidone Exposure Pirfenidone Short-termLong-term TGFβ mcg/mL αSMA^(a) SEM αSMA^(a) SEM αSMA^(a) SEM − 0 2.200.15 — — — — + 0 5.70 0.92 — — — — + 5 — — 6.76 1.05 4.72 0.90 + 25 — —5.34 0.33 4.04 0.93 + 125 — — —^(b) —^(b) 3.15 0.51 + 625 — — 3.57 0.792.47 0.32 ^(a)Fluorescence; ^(b)Not determined

Results from Table 36 show that pirfenidone is dose-responsive ininhibiting fibroblast differentiation. Similar to that shown in theinflammasome model, these data show that long-term pirfenidone exposure(in this case 48 hours) exhibits an IC50 of about 25 mcg/mL.Interestingly, short-term pirfenidone exposure was about 5-fold lessactive that longer-term exposure (IC50 about 125 mcg/mL).

TABLE 37 Impact of short-term pirfenidone exposure on TGFβ-inducedfibroblast differentiation. Pirfenidone Exposure Pirfenidone Short-termTGFβ mcg/mL αSMA^(a) SEM αSMA^(a) SEM − 0 1.73 0.08 — — + 0 6.65 0.72 —— + 1 — — 7.65 0.82 + 10 — — 7.75 0.70 + 100 — — 5.61 0.55 + 1000 — —2.27 0.06 ^(a)Fluorescence

To characterize a broader dose-response, the ability of short-termpirfenidone exposure to inhibit fibroblast differentiation was againassessed (Table 37). Similar to that shown in Table 36, these data showthat short-term pirfenidone exposure was about 5-fold less active thatlonger-term exposure. Considering these studies only evaluated a singleshort-term exposure compared to a constant 48 hour exposure, the actualIC50 values between these two exposure durations may be much closer,providing further support that only short-term pirfenidone exposure isrequired for activity.

In some embodiments, TGFβ induces ER stress in pulmonary fibroblasts. Insome embodiments, this ER stress results in activation of IRE1α andsubsequent expression of αSMA and collagen secretion. In furtherembodiments, inhibiting IRE1α reduces αSMA and collagen secretion. Insome embodiments, given these observations and pirfenidone's ability toinhibit the inflammasome and fibroblast differentiation at the same IC50suggests the mechanism behind these two events may be related.

Example 13. In Vivo Efficacy—LPS-Induced Pulmonary Inflammasome Model

To compare the efficacy of intratracheal, direct-lung aerosoladministration and oral gavage, the LPS-induced pulmonary inflammasomemodel was performed. Briefly, Sprague Dawley rats (200-250 grams) wereadministered a single dose of LPS by the intratracheal route (IT) usinga intubation aerosol delivery device. All IT doses were delivered justabove the first pulmonary bifurcation. Sham animals were treated withsaline. A single pirfenidone dose was either delivered by gavage (PO; 30mg/kg in 300 mcL) 2 hours before LPS exposure or IT (0.5 mg/kg in 300mcL LPS dosing solution) at the same time as LPS. After 24 hours,animals were euthanized. Lungs were lavaged and collected bronchiallavage fluid (BAL) was assessed for total cell count, neutrophils,macrophage, eosinophils and lymphocytes. BAL was also assessed forIL-lb. Data and results from these studies are shown in Tables 38 and39.

TABLE 38 BAL total cell count and differentials - Intratracheal aerosolversus oral Gavage. Group Pirfenidone Number cells^(a) and (%) (n = 4)(mg/kg) MP NP EO LM Sham + IT 0.0 Average 6.5 (82.7) 1.4 (16.3) 0.0(0.3) 0.1 (0.9) saline SEM 0.7 (3.9)  0.6 (3.9)  0.0 (0.2) 0.0 (0.5)LPS + IT 0.0 Average 11.3 (55.8)  13.0 (42.9)  0.2 (0.8) 0.2 (0.6)saline SEM 4.6 (12.7) 6.5 (12.5) 0.1 (0.3) 0.1 (0.2) LPS + PO 30.0Average 15.8 (62.2)  13.2 (36.4)  0.3 (0.6) 0.3 (0.9) pirfenidone SEM5.6 (15.7) 6.1 (15.8) 0.2 (0.4) 0.2 (0.5) LPS + IT 0.5 Average 6.2(85.4) 0.7 (13.0) 0.0 (0.7) 0.1 (1.0) pirfenidone SEM 1.8 (13.3) 0.7(13.0) 0.0 (0.5) 0.1 (0.8) ^(a)Number cells in 1 × 10e5. MP: macrophage;NP: neutrophils; EO: eosinophil; LM: lymphocytes.

TABLE 39 BAL IL-1β levels - Intratracheal aerosol versus oral Gavage.BAL LPS- Pirfenidone IL-1β induced Group (n = 4) (mg/kg) (pg/mL) IL-1β(%) Sham + IT saline 0.0 Average 0.7 NA SEM 0.7 LPS + IT saline 0.0Average 94.0 100 SEM 35.3 LPS + PO pirfenidone 30.0 Average 105.9 113SEM 40.9 LPS + IT pirfenidone 0.5 Average 36.2 38 SEM 22.0

Results from Tables 38 and 39 suggest that 0.5 mg/kg given directly tothe lung negated LPS-induced inflammatory cell infiltration and reducedLPS-induced BAL IL-1β levels 62%. By comparison, a 60-fold larger oraldose had no effect on either endpoint. From data described herein, it isestimated that the 0.5 mg/kg IT resulted in a lung tissue Cmax˜83mcg/gram, with very low blood levels. By comparison, Table 22 shows thata 30 mg/kg PO dose to a similar size rat results in a lung tissueCmax˜10 mcg/mL, with substantially greater blood levels. Together withExamples 9 and 12, these results further support that only short-termpirfenidone exposure is required for activity and that direct lungadministration enables delivery of high lung Cmax levels not possible byoral delivery.

Example 14: Nebulization Device Performance

To evaluate aerosol performance, several formulations (Table 40) weretested in the AKITA JET and AKITA2 APIXNEB Nebulizer System devices.Particle size distribution was determined using an HELOS Particle Sizer.Device input parameters are shown in Table 41. Results from thesestudies are shown in Tables 42 to 45. Each result is an average ofduplicate trials in each of three devices.

TABLE 40 Device characterization formulations Ingredient Formulation 1Formulation 2 Pirfenidone (mg/mL) 15.0 4.0 Sodium citrate, dihydrate(mM) 3.5 3.5 Citric acid, monohydrate (mM) 1.5 1.5 Sodium Chloride (mM)150.0 150.0 Sodium Saccharin (mM) 0.9 0.9 Water (q.s.) q.s. q.s.

TABLE 41 Device input parameters Inhale Exhale Nebulization Help InhaleExhale time per time per time per Bolus Bolus Flow volume volume breathbreath breath depth width rate Device (mL) (mL) (sec) (sec) (sec) (mL)(mL) (L/min) AKITA ® 1600 1600 8 8 7 1600 1400 12 Jet AKITA ®2 1600 16006.4 6.4 5.4 1600 1350 15 APIXNEB

TABLE 42 AKITA ®2 APIXNEB aerosol particle sizing Formulation (Table40): 1 2 Fill volume: mL  2.0 2.0 Label claim mg/mL 15.0 4.0 VMD (stdv)μm 4.14 (0.24) 4.15 (0.12) GSD (stdv) 1.60 (0.04) 1.59 (0.03) RF^(a)(stdv) % 65.6 66.7  ^(a)Respirable fraction (RF) is the percent ofnebulized particles <5 μm.

TABLE 43 AKITA ® Jet aerosol particle sizing Formulation (Table 40): 1 2Fill volume: mL 2.0 2.0 Label claim mg/mL 15.0  4.0 VMD (stdv) μm 3.25(0.08) 3.32 (0.11) GSD (stdv) 2.04 (0.01) 1.99 (0.01) RF^(a) (stdv) %71.44 70.85 ^(a)Respirable fraction (RF) is the percent of nebulizedparticles <5 μm.

TABLE 44 AKITA ®2 APIXNEB aerosol breath simulation Formulation (Table40): 1 2 Fill Volume mL 2.0 2.0 Label Claim mg/mL 15.0 4.0 Inhaled Dosemg 29.32 7.92 Inhaled Dose % 97.73 98.95 Nebulization Time min 4.55 5.01TOR^(a) mg/min 6.44 1.58 RDD^(b) mg 19.23 5.28 ^(a)Total output rate(TOR); ^(b)Respirable delivered dose (RDD) calculated by multiplying theinhaled dose (mg) and respirable fraction (Table 42).

TABLE 45 AKITA ® Jet aerosol breath simulation Formulation (Table 40): 12 Fill Volume mL 2.0 2.0 Label Claim mg/mL 15.0 4.0 Inhaled Dose mg14.99 3.52 Inhaled Dose % 50.00 44.06 Nebulization Time min 6.58 6.58TOR^(a) mg/min 2.28 0.54 RDD^(b) mg 10.71 2.49 ^(a)Total output rate(TOR); ^(b)Respirable delivered dose (RDD) calculated by multiplying theinhaled dose (mg) and respirable fraction (Table 43).

These results show that 2 mL of a 15 mg/mL pirfenidone formulation willbe administered in 4.55 minutes and 6.58 minutes and result in a 10.71mg and 2.49 mg RDD for the AKITA®2 APIXNEB and AKITA® Jet NebulizerSystem devices, respectively. These results also show that 2 mL of a 4mg/mL pirfenidone formulation will be administered in 5.01 minutes and6.58 minutes and result in a 5.28 mg and 2.49 mg RDD for the AKITA®2APIXNEB and AKITA® Jet Nebulizer System devices, respectively.Manipulation of the pirfenidone concentration and device fill volumewill permit optimization of dose delivery time and lung Cmax/plasmaexposure ratio.

The various embodiments described above can be combined to providefurther embodiments. All of the U.S. patents, U.S. patent applicationpublications, U.S. patent applications, foreign patents, foreign patentapplications and non-patent publications referred to in thisspecification are incorporated herein by reference, in their entirety.Aspects of the embodiments can be modified, if necessary to employconcepts of the various patents, applications and publications toprovide yet further embodiments. These and other changes can be made tothe embodiments in light of the above-detailed description. In general,in the following claims, the terms used should not be construed to limitthe claims to the specific embodiments disclosed in the specificationand the claims, but should be construed to include all possibleembodiments along with the full scope of equivalents to which suchclaims are entitled. Accordingly, the claims are not limited by thedisclosure.

What is claimed is:
 1. A method of decreasing IL-1β levels in the lungs of a mammal diagnosed with pulmonary fibrosis comprising administering by inhalation the aqueous solution of claim 1 to the mammal diagnosed with pulmonary fibrosis, wherein the administration of the aqueous solution to the mammal decreases IL-1β levels in the bronchial lavage fluid (BAL) of the mammal by at least 20%.
 2. The method of claim 1, wherein the pulmonary fibrosis is idiopathic pulmonary fibrosis (IPF) or pulmonary fibrosis associated with systemic sclerosis, radiation exposure or transplant.
 3. A method for the treatment of lung disease in a mammal comprising: administering by inhalation a dose of the aqueous solution of claim 1 to the mammal in need thereof on a continuous dosing schedule.
 4. The method of claim 3, wherein the lung disease is idiopathic pulmonary fibrosis, or pulmonary fibrosis associated with systemic sclerosis, radiation exposure or transplant, lung cancer or pulmonary hypertension.
 5. The method of claim 4, wherein the lung disease is lung cancer and the treatment comprises inhibiting, reducing or slowing the growth of lung tumor stroma.
 6. The method of claim 3, wherein the aqueous solution is administered by inhalation to the mammal in need thereof with a liquid nebulizer.
 7. The method of claim 6, wherein the liquid nebulizer is a jet nebulizer, an ultrasonic nebulizer, a pulsating membrane nebulizer, a nebulizer comprising a vibrating mesh or plate with multiple apertures, a nebulizer comprising a vibration generator and an aqueous chamber, or a nebulizer that uses controlled device features to assist inspiratory flow of the aerosolized aqueous solution to the lungs of the mammal.
 8. The method of claim 7, wherein the liquid nebulizer: (i) after administration of the inhaled dose, achieves lung deposition of at least 7% of the pirfenidone administered to the mammal; (ii) provides a Geometric Standard Deviation (GSD) of emitted droplet size distribution of the aqueous solution of about 1.0 μm to about 2.5 μm; (iii) provides droplets of the aqueous solution emitted with the high efficiency liquid with: a) a mass median aerodynamic diameter (MMAD) of about 1 μm to about 5 μm; b) a volumetric mean diameter (VMD) of about 1 μm to about 5 μm; and/or c) a mass median diameter (MMD) of about 1 μm to about 5 μm; (iv) provides a fine particle fraction (FPF=% ≤5 μm) of droplets emitted from the liquid nebulizer of at least about 30%; (v) provides an output rate of at least 0.1 mL/min; and/or (vi) provides at least about 25% of the aqueous solution to the mammal.
 9. The method of claim 3, wherein the dose of the aqueous solution of pirfenidone is administered at least once a week.
 10. The method of claim 3, wherein the dose of the aqueous solution of pirfenidone is administered on a continuous daily dosing schedule.
 11. The method of claim 3, wherein the dose of the aqueous solution of pirfenidone is administered once a day, twice a day, three times a day, four times a day, five times a day, or six times a day.
 12. The method of claim 3, wherein each dose of the aqueous solution of pirfenidone is administered within 20 minutes.
 13. The method of claim 3, wherein the method further comprises administration of one or more additional therapeutic agents to the mammal. 